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An 81-year-old woman who had previously undergone left hemicolectomy for an adenocarcinoma (pT3 N1) of the descending colon was diagnosed with a 2-cm flat polyp in the transverse colon during surveillance colonoscopy (●" Fig.1a). Subsequently, she also developed liver metastases and underwent three cycles of neoadjuvant chemotherapy with leucovorin, 5-fluorouracil, irinotecan, and bevacizumab (325mg per cycle). Five days following the last infusion, she underwent colonoscopy with piecemeal endoscopic mucosal resection (EMR) of the polyp.The polyp margins were treated with hot biopsy forceps (●" Fig.1b, ●" Fig.1c). A few hours post-EMR, the patient developed abdominal pain and signs of localized peritonitis. An urgent computed tomography (CT) scan showed severe edema around the EMR site and air in themesocolon, but no free air (●" Video 1). The patient underwent emergency laparotomy, which revealed a 10-cm necrotic segment in the transverse colon distal to the EMR site. A perforation site was noted at the distal end of the necrotic segment but not at the EMR site. Resection of this segment was performed and a stoma was sited. Histopathology of the surgical specimen showed florid ischemic changes (●" Fig.2). The patient had an uneventful postoperative recovery. Bevacizumab is a recombinant monoclonal antibody that blocks angiogenesis, thereby inhibiting tumor growth. In patients undergoing bevacizumab treatment, perforation risks of 0.9% in general [1] and 12.5% following colonic stenting [2] have been reported. Recent colonoscopy (<1 month) is a risk factor for bevacizumab-related perforation [1]. This case illustrates that bowel ischemia is probably the culprit behind perforation in these patients, as has been previously proposed in patients receiving bevacizumab following radiotherapy [3]. It is conceivable that bevacizumab-related ischemia may have been aggravated by bowel preparation, luminal instrumentation, and adrenalin injection, therefore resulting in ischemia-related bowel perforation. Stopping bevacizumab for at least 28 days before and after surgical procedures is recommended [4], and this would also be reasonable for colonoscopy procedures, unless they are clinically essential.

Colonic perforation following endoscopic mucosal resection in a patient on bevacizumab treatment