Clinical features and risk factors for colorectal gas explosion during digestive endoscopy and surgery: a systematic review

Background and aims: Colorectal gas explosion (CGE) is an exceptional but potentially fatal complication of digestive endoscopy or surgery. The role played by bowel preparations and endoscopic or surgical devices in the risk of CGE is still unclear. We conducted a systematic review of the literature to identify risk factors for CGE. Methods: We conducted a comprehensive literature search of multiple databases from inception to September 16, 2024 including all reports of CGE according to a systematic review protocol preregistered on the PROSPERO database (CRD42023455049). Additionally, we analyzed all trials that measured explosive gas levels after different bowel preparation strategies. Results: Twenty-nine case reports, three case series, and eleven trials were included. Thirty-six cases of CGE were described, 12 surgical and 24 endoscopic. Perforation and death following CGE occurred in 81% and 14% of patients, respectively. The most common bowel preparations taken before CGE were enemas (42%) and oral preparations (31%), while 28% of patients did not undergo any bowel preparation. Bowel preparation was reported as inadequate in most CGE (solid stool in 65% and poor in 11%). The most frequent devices that triggered CGE were argon plasma coagulation during endoscopy (58%) and the electric scalpel during surgical procedures (75%). Published trials showed that adequate bowel preparation, together with endoscopic insufflation and suction, reduces intestinal levels of hydrogen and methane. Conclusions: CGE predominantly occurs in patients undergoing interventional procedures with inadequate bowel preparation. Achieving optimal bowel preparation, together with endoscopic aspiration, washing, and CO2 insufflation practically abolishes potentially explosive gas concentrations.