title: Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis.
abstract: OBJECTIVE
  Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training.
  
  
  METHODS
  We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol.
  
  
  RESULTS
  We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation.
  
  
  CONCLUSIONS
  In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.
authors.affiliation: Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario, Canada.
authors.forename: Barbara
authors.initials: B
authors.lastname: Bielawska
authors.affiliation: Clinical Research Centre, Kingston General Hospital, Kingston, Ontario, Canada.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Day
authors.affiliation: Division of Gastroenterology, Oregon Health Sciences University, Portland Veterans Affairs Medical Center, Portland, Oregon.
authors.forename: David A
authors.initials: DA
authors.lastname: Lieberman
authors.affiliation: Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario, Canada. Electronic address: hookeyl@hdh.kari.net.
authors.forename: Lawrence C
authors.initials: LC
authors.lastname: Hookey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003113:Colonoscopy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011361:Professional Competence; D012189:Retrospective Studies; D012307:Risk Factors
keywords: ASA; ASA Classification; American Society of Anesthesia; CI; CORI; Clinical Outcomes Research Initiative; Endoscopy Training; GI; HMO; IBD; Intestine; OR; Quality Control; VA; Veterans Affairs; confidence interval; health maintenance organization; inflammatory bowel disease; odds ratio
references.citation: Am J Surg. 1992 Feb;163(2):257-9
references.pmid: 1739182
references.citation: Colorectal Dis. 2010 Oct;12(10 Online):e273-7
references.pmid: 19930145
references.citation: Gastrointest Endosc. 2009 Mar;69(3 Pt 2):654-64
references.pmid: 19251006
references.citation: Gastrointest Endosc. 2008 May;67(6):910-23
references.pmid: 18440381
references.citation: Gastrointest Endosc. 2005 Jul;62(1):9-15
references.pmid: 15990813
references.citation: Can J Gastroenterol. 2009 May;23(5):342-4
references.pmid: 19440563
references.citation: JAMA Intern Med. 2013 Apr 8;173(7):551-6
references.pmid: 23478904
references.citation: Cancer. 2012 Jun 15;118(12):3044-52
references.pmid: 21989586
references.citation: Gastrointest Endosc. 2008 Mar;67(3):489-96
references.pmid: 18179793
references.citation: Ann Intern Med. 1993 Jan 1;118(1):40-4
references.pmid: 8416157
references.citation: Endoscopy. 2011 Nov;43(11):935-40
references.pmid: 21997723
references.citation: Am J Gastroenterol. 2004 Jan;99(1):52-6
references.pmid: 14687141
references.citation: Surg Endosc. 2010 Oct;24(10):2556-61
references.pmid: 20339876
references.citation: Curr Opin Anaesthesiol. 2009 Aug;22(4):524-31
references.pmid: 19512913
references.citation: Endoscopy. 2009 Nov;41(11):941-51
references.pmid: 19866393
references.citation: Gastroenterology. 2008 Dec;135(6):1899-1906, 1906.e1
references.pmid: 18938166
references.citation: Gastrointest Endosc. 2008 Dec;68(6):1056-62
references.pmid: 18640675
references.citation: J Gastrointest Surg. 2008 Oct;12(10):1783-9
references.pmid: 18683006
references.citation: J Gastrointest Surg. 2005 Dec;9(9):1229-35: discussion 1236
references.pmid: 16332478
references.citation: Clin Gastroenterol Hepatol. 2010 Mar;8(3):275-9
references.pmid: 19879970
references.citation: Arch Surg. 2009 Jan;144(1):9-13
references.pmid: 19153318
references.citation: Gastrointest Endosc Clin N Am. 2005 Oct;15(4):661-72
references.pmid: 16278131
references.citation: Arch Surg. 2008 Jul;143(7):701-6; discussion 706-7
references.pmid: 18645114
references.citation: Mayo Clin Proc. 1997 Aug;72(8):729-33
references.pmid: 9276600
references.citation: Am J Gastroenterol. 2003 Aug;98(8):1744-50
references.pmid: 12907328
references.citation: Surg Endosc. 2007 Jun;21(6):994-7
references.pmid: 17453289
references.citation: J Clin Gastroenterol. 2010 Mar;44(3):161-6
references.pmid: 20042871
references.citation: N Engl J Med. 2010 May 13;362(19):1795-803
references.pmid: 20463339
references.citation: Gastroenterology. 2007 Jan;132(1):96-102
references.pmid: 17241863
references.citation: Am Surg. 2004 Sep;70(9):750-7; discussion 757-8
references.pmid: 15481289