0016-5107/81/2703-0184$02.00/0 GASTROINTESTINAL ENDOSCOPY Copyright © 1981 by the American Society for Gastrointestinal Endoscopy Symposium Selected papers from the Second International Congress on Colonoscopy and Diseases of the Large Bowel, March 6 to 8, 1980 John P. Christie, MD Bernard Levin, MD Editors The postpolypectomy coagulation syndrome Jerome D. Waye, MD The major complications of colonoscopic polypectomy are perforation and bleeding, but there is another complication which I have called the "postpolypectomy coagulation syndrome." So far, this has not appeared in the medical literature, but it is a very real problem for those who remove colon polyps. The "coagulation syndrome" occurs after polypectomy and consists of localized abdominal pain, signs of peritoneal irritation, and fever. This syndrome is caused by thermal injury to tissue during electrocautery. Tissue necrosis extends into the submucosa, causing a variable amount of symptomatic reaction. Pa- tients with diverticulitis or appendicitis have the same findings as are seen in the "postpolypectomy coagulation syndrome." They, too, have signs of peritoneal inflammation such as pain on palpation, rebound tenderness, fever, and leukocytosis. The pain is usually located at the site of polypectomy. The syndrome occurs with pedunculated polyps but is much more frequent with removal of sessile lesions. This syndrome is not produced by a contralateral wall burn, which occurs very rarely, in my opinion. As much as everyone is concerned about having a polyp touching the opposite wall during cautery removal, significant wall burns are extremely unusual. The removal of a sessile polyp with a fairly broad base necessitates a lot of coagulation current at the level of the colon wall. The longer the current is applied, the greater the degree of thermal coagulation From the Gastrointestinal Endoscopy Section, Mount Sinai School of Medicine, New York, New York. 184 of normal colonic tissue. It is in those patients from whom a wide based colon polyp is resected that we may expect to find evidence of peritoneal irritation. One has to be very careful how one applies the snare to a polyp before stepping on the cautery pedal. If the snare is not completely tightened around the base of the polyp, and a portion of the snare is in contact with the bowel wall, a severe localized burn may be produced during current application. A similar, but more significant, complication may occur when a piece of normal wall mucosa becomes incarcerated within the loop and is compressed with the pedicle of a polyp when the snare is closed. A free perforation may ensue or the patient may develop the postpolypectomy coagulation syndrome. The postpolypectomy syndrome is not due to perforation, but this must always be considered and excluded when symptoms occur within 12 hours following polypectomy. If the patient complains of pain or develops a fever (sometimes as high as 102°q, peritoneal irritation, and leukocytosis, obtain three positional films of the abdomen to exclude free air. Op- eration for patients with the syndrome must be avoided because they do very well with conservative therapy. (If laparotomy is performed inadvertently, a whitening of the serosa at the site of polypectomy and some serous fluid in the peritoneal cavity are seen.) Oral intake is discontinued and intravenous fluids given. Antibiotics are administered if considered necessary. Careful observation is essential. All endoscopists should know about this complication so as to avoid premature exploratory laparotomy. Of course, if the patient's condition deteriorates or free peritoneal air is noted, it means a perforation has occurred, but usually a transmural burn is associated with a benign outcome. GASTROINTESTINAL ENDOSCOPY

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Page 1: The postpolypectomy coagulation syndrome

Symposium

Selected papers from the SecondInternational Congress on Colonoscopy andDiseases of the Large Bowel, March 6 to 8,1980

John P. Christie, MDBernard Levin, MD

Editors

The postpolypectomy coagulation syndromeJerome D. Waye, MD

The major complications of colonoscopic polypectomy are perforation and bleeding, but there is anothercomplication which I have called the "postpolypectomy coagulation syndrome." So far, this has not appeared in the medical literature, but it is a very realproblem for those who remove colon polyps. The"coagulation syndrome" occurs after polypectomyand consists of localized abdominal pain, signs ofperitoneal irritation, and fever. This syndrome iscaused by thermal injury to tissue during electrocautery. Tissue necrosis extends into the submucosa, causing a variable amount of symptomatic reaction. Patients with diverticulitis or appendicitis have the samefindings as are seen in the "postpolypectomy coagulation syndrome." They, too, have signs of peritonealinflammation such as pain on palpation, reboundtenderness, fever, and leukocytosis. The pain is usuallylocated at the site of polypectomy. The syndromeoccurs with pedunculated polyps but is much morefrequent with removal of sessile lesions. This syndromeis not produced by a contralateral wall burn, whichoccurs very rarely, in my opinion. As much as everyoneis concerned about having a polyp touching the opposite wall during cautery removal, significant wallburns are extremely unusual.

The removal of a sessile polyp with a fairly broadbase necessitates a lot of coagulation current at thelevel of the colon wall. The longer the current isapplied, the greater the degree of thermal coagulation

From the Gastrointestinal Endoscopy Section, Mount Sinai Schoolof Medicine, New York, New York.

184

of normal colonic tissue. It is in those patients fromwhom a wide based colon polyp is resected that wemay expect to find evidence of peritoneal irritation.One has to be very careful how one applies the snareto a polyp before stepping on the cautery pedal. If thesnare is not completely tightened around the base ofthe polyp, and a portion of the snare is in contact withthe bowel wall, a severe localized burn may be produced during current application. A similar, but moresignificant, complication may occur when a piece ofnormal wall mucosa becomes incarcerated within theloop and is compressed with the pedicle of a polypwhen the snare is closed. A free perforation may ensueor the patient may develop the postpolypectomy coagulation syndrome.

The postpolypectomy syndrome is not due to perforation, but this must always be considered and excluded when symptoms occur within 12 hours following polypectomy. If the patient complains of pain ordevelops a fever (sometimes as high as 102°q, peritoneal irritation, and leukocytosis, obtain three positional films of the abdomen to exclude free air. Operation for patients with the syndrome must beavoided because they do very well with conservativetherapy. (If laparotomy is performed inadvertently, awhitening of the serosa at the site of polypectomy andsome serous fluid in the peritoneal cavity are seen.)Oral intake is discontinued and intravenous fluidsgiven. Antibiotics are administered if considered necessary. Careful observation is essential.

All endoscopists should know about this complication so as to avoid premature exploratory laparotomy.Of course, if the patient's condition deteriorates orfree peritoneal air is noted, it means a perforation hasoccurred, but usually a transmural burn is associatedwith a benign outcome.

GASTROINTESTINAL ENDOSCOPY