Feasibility assessment of outpatient colorectal resections at a tertiary referral center.

PURPOSE: Enhanced Recovery After Surgery (ERAS) protocols, particularly when paired with advanced laparoscopy, have reduced recovery time following colorectal procedures. The aim of this study was to determine if length of stay (LOS) could be reduced to an overnight observation stay (< 24 h) with comparable perioperative morbidity. The secondary aim was to establish predictive factors contributing to early discharge. METHODS: This is a retrospective cohort study of all colectomies at a tertiary care center between January 2016 and January 2019. Inclusion criteria included all colorectal resections with varying surgical approaches. Patients underwent a standardized ERAS protocol. A logistical regression model was conducted for predictive factors. RESULTS: Three hundred sixty patients were included (55.3% female). Of these, 78 (21.7%) patients were discharged within < 24 h and 112 (31.1%) were discharged within 24-48 h. The remainder comprised the > 48 h group. Age differed significantly between the < 24 h and 24-48 h groups (p < 0.0001). Patients discharged within 24 h were younger (59.4 ± 12.3 years), had a lower CCI score (3.1; p = 0.0026), and lower ASA class (p < 0.0001). Emergency department visits (p = 0.3329) and readmissions (p = 0.6453) prior to POD 30 remained comparable among all groups. Younger age, low ASA, and minimally invasive surgical approach all contributed to ultra-fast discharge. CONCLUSION: ERAS protocols may allow for discharge within 24 h following a major colorectal resection, all with low perioperative morbidity and mortality. The predictive factors for discharge within 24 h include a low ASA (I or II), and a minimally invasive surgical approach.

Preclinical evaluation of the versius surgical system, a new robot-assisted surgical device for use in minimal access general and colorectal procedures.

OBJECTIVE: To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting. Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots. METHODS: Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device's safety in performing cholecystectomy or small bowel enterotomy. RESULTS: Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons' preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications. CONCLUSIONS: This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.

S128: Active post discharge surveillance program as a part of Enhanced Recovery After Surgery protocol decreases emergency department visits and readmissions in colorectal patients.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs aim to standardize perioperative care to reduce morbidity and cost. Our study examined an Active Post-Discharge Surveillance (APDS) program in reducing avoidable readmissions and emergency department (ED) visits in postoperative colorectal ERAS patients. METHODS: Colectomy (right, subtotal and total) and low anterior resection cases performed at a tertiary care hospital between 2015 and 2018 were reviewed. ED visits, 30-day readmissions, and patients' APDS participation were assessed. Our APDS followed a modern text messaging paradigm offered to all patients free-of-charge. RESULTS: Of 236 patients that underwent colectomy, 123 utilized APDS and 113 did not. Overall, both non-surveillance (NS) and active surveillance (AS) groups had similar preoperative characteristics. Length of hospital stay at index surgery was longer in the NS compared to AS group, 4.7 ± 2.6 vs. 2.6 ± 2.8 days, respectively (p < 0.001). In the NS group, 16 patients visited the ED, of which 14 (14/16, 87.5%) were ultimately readmitted. One patient was directly readmitted from the surgeon's office, resulting in a total of 15 (15/113, 13.3%) total patients readmitted by postoperative day (POD) 30. In the AS group, 9 patients visited the ED, of which 7 (7/9, 77.8%) were ultimately readmitted. One patient was directly readmitted, resulting in a total of 8 (8/123, 6.5%) total patients readmitted by POD 30. AS patients had significantly lower odds of visiting the ED when compared to NS patients (OR: 0.356; 95% CI: 0.138-0.919; p = 0.0328). Similarly, AS patients had significantly lower odds of readmission when compared to NS patients (OR: 0.343; 95% CI: 0.132-0.892; p = 0.0283). CONCLUSIONS: APDS allows many postoperative issues to be resolved in outpatient settings without ER visits or readmission. This indicates APDS is a valuable ERAS adjunct by establishing a cost-effective and convenient communication line between patients and their surgical team.

Rectal Dissection Simulator for da Vinci Surgery: Details of Simulator Manufacturing With Evidence of Construct, Face, and Content Validity.

BACKGROUND: Apprenticeship in training new surgical skills is problematic, because it involves human subjects. To date there are limited inanimate trainers for rectal surgery. OBJECTIVE: The purpose of this article is to present manufacturing details accompanied by evidence of construct, face, and content validity for a robotic rectal dissection simulation. DESIGN: Residents versus experts were recruited and tested on performing simulated total mesorectal excision. Time for each dissection was recorded. Effectiveness of retraction to achieve adequate exposure was scored on a dichotomous yes-or-no scale. Number of critical errors was counted. Dissection quality was tested using a visual 7-point Likert scale. The times and scores were then compared to assess construct validity. Two scorer results were used to show interobserver agreement. A 5-point Likert scale questionnaire was administered to each participant inquiring about basic demographics, surgical experience, and opinion of the simulator. Survey data relevant to the determination of face validity (realism and ease of use) and content validity (appropriateness and usefulness) were then analyzed. SETTINGS: The study was conducted at a single teaching institution. SUBJECTS: Residents and trained surgeons were included. INTERVENTION: The study intervention included total mesorectal excision on an inanimate model. MAIN OUTCOME MEASURES: Metrics confirming or refuting that the model can distinguish between novices and experts were measured. RESULTS: A total of 19 residents and 9 experts were recruited. The residents versus experts comparison featured average completion times of 31.3 versus 10.3 minutes, percentage achieving adequate exposure of 5.3% versus 88.9%, number of errors of 31.9 versus 3.9, and dissection quality scores of 1.8 versus 5.2. Interobserver correlations of R = 0.977 or better confirmed interobserver agreement. Overall average scores were 4.2 of 5.0 for face validation and 4.5 of 5.0 for content validation. LIMITATIONS: The use of a da Vinci microblade instead of hook electrocautery was a study limitation. CONCLUSIONS: The pelvic model showed evidence of construct validity, because all of the measured performance indicators accurately differentiated the 2 groups studied. Furthermore, study participants provided evidence for the simulator's face and content validity. These results justify proceeding to the next stage of validation, which consists of evaluating predictive and concurrent validity. See Video Abstract at http://links.lww.com/DCR/A551.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND: Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement. OBJECTIVE: The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence. DESIGN AND SETTINGS: A retrospective review was performed at 3 university-affiliated teaching hospitals. PATIENTS: All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded. MAIN OUTCOME MEASURES: The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed. RESULTS: Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Bio-Thiersch as an Adjunct to Perineal Proctectomy Reduces Rates of Recurrent Rectal Prolapse.

BACKGROUND: The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence. OBJECTIVE: The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone. DESIGN: A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed. SETTINGS: Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital. PATIENTS: Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared. INTERVENTIONS: All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct. MAIN OUTCOME MEASURES: The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented. RESULTS: Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05). LIMITATIONS: This study was limited by nature of being a retrospective review. CONCLUSIONS: Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors.

BACKGROUND: Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity. METHODS: Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed. RESULTS: All procedures were successfully completed without conversion. Average body mass index was 32 kg/m2. The mean operative time and blood loss were 370 min and 130 ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14 months, all patients remain disease-free. CONCLUSIONS: Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.

Robot-Assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes.

BACKGROUND: The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. OBJECTIVE: We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 5-year period. SETTING: Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. PATIENTS: Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. INTERVENTIONS: All patients received a robot-assisted extralevator abdominoperineal resection. MAIN OUTCOME MEASURES: Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. RESULTS: Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. LIMITATIONS: This was a single-institution study with no comparative open or laparoscopic group. CONCLUSION: Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

Endoscopic control of enterocutaneous fistula by dual intussuscepting stent technique.

INTRODUCTION: Large high-output enterocutaneous fistulas pose great difficulties, especially in the setting of recent surgery and compromised skin integrity. METHODS: This video demonstrates a new technique of endoscopic control of enterocutaneous fistula by using two covered overlapping stents. In brief, the two stents are each inserted endoscopically, one proximal, and the other distal to the fistula with 2 cm of each stent protruding cutaneously. Following this, the proximal stent is crimped and intussuscepted into the distal stent with an adequate overlap. A prolene suture is passed through the anterior wall of both stents to prevent migration. The two stents used were evolution esophageal stents-10 cm long, fully covered, double-flared with non-flared and flared diameters being 20 and 25 mm, respectively (product number EVO-FC-20-25-10-E, Cook Medical, Bloomington, IN, USA). RESULTS: The patient featured in this video developed a high-output enterocutaneous fistula proximal to a loop ileostomy, which was created following a small bowel leak after a curative surgery for bladder cancer. Using the technique featured in this video (schematic depicted in Fig. 1), the patient was nutritionally optimized with oral feeds from albumin of 0.9-3.4 g/dl within 2 months despite prior failure to achieve nutrition optimization and adequate skin protection with combination of oral and/or parenteral nutrition. Three months after stenting, following nutritional optimization and improvement of skin coverage, definitive procedure consisted of uncomplicated fistula resection with primary stapled side-to-side functional end-to-end anastomosis. The stents were not completely incorporated into the mucosa and were rather easily pulled through the residual fistula opening just prior to the surgery. Only minimal fibrosis was noted and less than 20 cm of involved small bowel needed to be resected. Had the fistula have closed completely, the options would have included (1) proceeding to bowel resection with removal of the stents regardless of closure, or (2) cutting the securing prolene stitch and observation. Considering the placement of the stents in mid-small bowel, their endoscopic retrieval would have been difficult unless they were to migrate into the colon. CONCLUSIONS: Although a prior attempt at managing an enterocutaneous fistula with a stent deployed through a colostomy site was previously reported [1], there is no published account of bridging an enterocutaneous fistula with overlapping endoscopic stents through the fistula itself. This video serves as a proof of concept for temporizing enterocutaneous fistulas with endoscopic stenting.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. OBJECTIVE: We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 7-year period. SETTINGS: Procedures took place in the colorectal division at a tertiary hospital. PATIENTS: From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. INTERVENTIONS: Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. MAIN OUTCOME MEASURES: Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. RESULTS: There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005). LIMITATIONS: This was a single-institution study with no head-to-head comparative group. CONCLUSIONS: Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.

Current status of robotic surgery for rectal cancer: A bird's eye view.

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors' own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included.

Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery.

BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twenty-three patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures.

Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program.

BACKGROUND: Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions. METHODS: This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997-2008. RESULTS: Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2-1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks. CONCLUSIONS: Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.

Endoclip closure of a large colonic perforation following colonoscopic leiomyoma excision.

BACKGROUND AND OBJECTIVE: Endoscopic removal of large colonic submucosal lesions can lead to a higher risk of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more often following therapeutic colonoscopy. We present a case of a large submucosal mass excised endoscopically, resulting in a large perforation that was closed using endoclips. While endoclips are typically used for smaller perforations, we have found that they can be used safely on a larger defect. METHODS: A 68-y-old woman presented with a 2.9-cm benign submucosal mass found in the hepatic flexure. It was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with endoscopic clips. RESULTS: Histology of the specimen showed clear margins. At 4-wk follow-up, the patient had no complications. A colonoscopy at 6-mo follow-up showed only a scar at the procedure site with no complaints. CONCLUSIONS: Large iatrogenic colonic perforations can be managed successfully using endoclips, particularly in a prepped colon.