Original article
Clinical endoscopy
Risk of perforation from a colonoscopy in adults: a large population-based study

https://doi.org/10.1016/j.gie.2008.09.008Get rights and content

Background

Previous studies that reported the incidence of perforation from a colonoscopy are limited by small sample sizes, restricted age groups, or single-center data.

Objective

To determine the incidence and risk factors of colonic perforation from a colonoscopy in a large population cohort.

Design

Retrospective, population-based, cohort study, followed by a nested case-control study.

Setting

California Medicaid program claims database.

Patients

A total of 277,434 patients (aged 18 years and older) who underwent a colonoscopy during 1995 to 2005, age, sex, and time matched to 4 unique general-population controls.

Main Outcome Measurements

Perforation incidence in the 7 days after colonoscopy (or matched index date for controls) with odds ratio (OR); multivariate logistic regression to calculate adjusted ORs for subsequent analysis of risk factors.

Results

A total of 228 perforations were diagnosed after 277,434 colonoscopies, which corresponded to a cumulative 7-day incidence of 0.082%. The OR of getting a perforation from a colonoscopy compared with matched controls (n = 1,072,723) who did not undergo a colonoscopy was 27.6 (95% CI, 19.04-39.92), P < .001. On multivariate analysis, when comparing the group that had a perforation after a colonoscopy (n = 216) with those who did not (n = 269,496), increasing age, significant comorbidity, obstruction as an indication for the colonoscopy, and performance of invasive interventions during colonoscopy were significant positive predictors. Performance of biopsy or polypectomy did not affect the perforation risk. The rate of perforation did not change significantly over time.

Limitations

Validity of coding and capturing of all perforation diagnoses may possibly be deficient.

Conclusion

The risk of perforation from a colonoscopy is low, but, despite increased experience with the procedure, it remains unchanged over time.

Section snippets

Database

The present study is based on longitudinal data derived from Medi-Cal, the Medicaid program for the state of California.46 The Medi-Cal program serves more than 6.5 million beneficiaries, of whom approximately 3.1 million (48%) are in the Fee-For-Service (FFS) system, whereas the remainder are enrolled in managed care plans.47 In 1994, 86% of the Medi-Cal beneficiaries received their care via the FFS program; this decreased to just over 50% in 2001 and has continued at that level thereafter.47,

Perforation rate and analysis of risk compared with general population controls

A total of 277,434 individuals (exposed cohort) met the 7-day continuous eligibility criterion (after excluding 241 patients who did not). The corresponding number in the control cohort was 1,072,723. The mean (SD) age was comparable in the exposed and control cohorts, at 64.20 ± 14.80 years (range 18-107.8 years) and 63.97 ± 14.99 years (range 18-107.9 years), respectively. Among the respective demographic groups (Table 3), women, people aged 65 to 80 years, and whites accounted for the

Discussion

Recent large studies showed perforation rates between 0.016% and 0.090%, depending on the center and the data source. Of note, 3 studies found perforation rates outside of this range. By using a mailed questionnaire, Sieg et al,36 prospectively evaluated 82,416 colonoscopies and found a low incidence of 0.005%. This could likely be explained by a selection bias because the physicians' self reported the perforations; also, only those perforations that required a surgical intervention were

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    DISCLOSURE: The following author disclosed financial relationships relevent to this publication: G. Triadafilopoulos: Equity position with Avantis Medical. All other authors disclosed no financial relationships relevent to this publication. This study was funded by Institute of Clinical Outcomes Research and Education, which did not play any role in the study design or conduct, analysis, or interpretation of data, or in the writing or approval of the manuscript.

    Presented at Digestive Disease Week, May 19-24, 2007, Washington DC (Gastrointest Endosc 2007;65:AB320).

    If you want to chat with an author of this article, you may contact him at [email protected].

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