Interventional gastroenterology

Costly colonoscopic perforations may be decreasing


Colonoscopic perforations are shifting costs from the private sector, where most of the scopes are performed, to the public system often managing them.

According to a review of perforations managed at tertiary referral unit in Victoria over a 13-year period, the estimated cost of managing a perforation was $13,435 with a median length of hospital stay of nine days.

For patients who require a stoma and subsequent reversal, the cost of the readmission was an additional $11,957 with a stay of 12 days.

The review identified 62 patients with perforations with a median age of 69 years.

Most patients (61.2%) had their colonoscopies in the private system with the vast majority (85%) of procedures leading to a perforation performed by experienced endoscopists rather than trainees.

While the study was not able to calculate perforation rates overall, in the subset of patients whose perforation occurred in the treating hospital, there was an overall incidence of 0.91 perforations per 1,000 colonoscopies.

However there was an indication that the rate of perforations was dropping over time with the incidence of perforations in the second half of the study period only 0.37 per 1000 colonoscopies.

The review found perforations were more likely to occur in diagnostic rather than therapeutic colonoscopies and most likely to occur in the left colon.

Only 18% of patients were successfully treated with conservative management and the rest underwent surgery. Median time from diagnosis to surgery was 11.4 hours.

“Patients with small perforations who are clinically stable may be managed expectantly with intravenous antibiotics and serial clinical review, including patients who have been managed with endoscopic clipping. If they show any signs of deterioration, then prompt transfer to theatre is essential,” the study said.

The researchers said that a number of advances had occurred in colonoscopy practice over the review period.

“In addition, improved training through colonoscopy courses run by the Gastroenterological Society of Australia, better access to training lists and mentorship to trainees may have had a positive impact on quality of endoscopy.”

A spokesperson for GESA told the limbic about 1,100 surgeons and physicians were currently engaged in the Colonoscopy Recertification Program – a major initiative to improve the quality of colonoscopy.

“We created a voluntary program and frankly it’s a massive credit to colonoscopists, both physicians and surgeons, that so many – up to about 50% at best guess – came into the system while it was still voluntary.”

The program was delivered at no cost from May 2016 until February this year with support from the National Bowel Cancer Screening Program. It now costs $840 for the three-year program.

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