Minute perforation after argon plasma coagulation for management of small colonic polyps

A 53-year-old woman presented with a 6-month history of chronic constipation and abdominal bloating. Because of concern about a colorectal lesion, colonoscopy was done and hundreds of small polyps were found throughout the colon, most being less than 4 mm in diameter. Some of the bigger polyps were removed by polypectomy and were found at pathologic examination to be tubular adenoma. As the patient was unwilling to undergo a rectum-preserving total colectomy, argon plasma coagulation (APC) was selected to ablate the remaining polyps as far as possible ([Fig. 1]).

Fig. 1 Most of the small polyps in the colon were ablated using argon plasma coagulation (APC).

APC was done using an Olympus system (PSD-60; Olympus, Tokyo, Japan) at settings of argon flow rate 1 l/minute, power 40 W, effect 1.

The patient tolerated the 1-hour procedure well until the end, when severe abdominal distension without rebound tenderness was noted. Because of the persistent abdominal discomfort, a standing chest radiograph was obtained which showed massive free air in the peritoneum ([Fig. 2]).

Fig. 2 At 3 hours after colonoscopy, a standing chest radiograph revealed massive pneumoperitoneum.

Laparotomy was done immediately. The entire colon was checked carefully and a tiny perforation was found at the transverse colon ([Fig. 3], arrow).

Fig. 3 At laparotomy, a tiny perforation (arrow) was found at the transverse colon.

After surgical closure of the perforation, the patient recovered uneventfully and was discharged 2 weeks later.

APC is safe and effective for the management of gastrointestinal tract bleeding, polyp remnants, and watermelon stomach, ablation of precancerous lesions, and so on [1] [2] [3]. An asymptomatic air accumulation in the peritoneum may develop after APC because the high argon flow induces submucosal emphysema with a leakage of gas through the gastrointestinal tract wall. Conservative treatment is suggested for this situation [4]. As our patient underwent APC ablation of numerous colonic polyps, the air insufflation was prolonged, leading to severe pneumoperitoneum even though there was only a tiny perforation. Thus, it is very important to distinguish between the symptomatic ‘perforation’ and the asymptomatic ‘air accumulation’ as causes of pneumoperitoneum.

Endoscopy_UCTN_Code_CPL_1AJ_2AI

References

• 1 Manner H, May A, Faerber M. et al . Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract.  Dig Liver Dis. 2006;  38 471-478
• 2 Izquierdo S, Rey E, Gutierrez Del Olmo A. et al . Polyp as a complication of argon plasma coagulation in watermelon stomach.  Endoscopy. 2005;  37 921
• 3 Neneman B, Gasiorowska A, Malecka-Panas E. The efficacy and safety of argon plasma coagulation (APC) in the management of polyp remnants in stomach and colon.  Adv Med Sci. 2006;  51 88-93
• 4 Manes G, Imbesi V, Bianchi-Porro G. Pneumoperitoneum after argon plasma coagulation treatment: perforation or accumulation of air in the cavity?.  Endoscopy. 2007;  39 Suppl 1 E98