OMENTAL PATCH FOR CLOSURE OF CAECUM PERFORATION DURING ENDOSCOPIC PIECEMEAL MUCOSAL RESECTION OF GRANULAR-LATERAL SPREADING TUMOR (LST-G) IN ULCERATIVE COLITIS PATIENT (WITH VIDEO)

Colorectal perforation is a rare but severe event related to therapeutic interventions. European guidelines recommend that endoscopic closure should be considered depending on the type of perforation, its size and endoscopist expertise. We report the case of caecum perforation during piecemeal EMR of large granular lateral spreading tumor (LST-G) in ulcerative colitis patients, treated by omental patching.

Material and methods:

A 65-year-old man with a long history of Ulcerative Colitis (UC) was referred to our Institution for the endoscopic treatment of a LST-G of the caecum, 45 mm diameter. The lesion was treated by EMR, performed by a standard HD colonscope (Fujifilm EG-6000WR) under deep sedation and CO₂ insufflation.

Results:

After chromoendoscopy with indigo carmine and margins marking, injection of diluted adrenaline (1:10.000) into submucosal space was performed. Submucosal injection was difficult for the presence of fibrosis, but an initial mucosal resection was carried out (lifting sign +/-); for this reason we decided to proceed underwater: the lumen was filled with room temperature water and air insufflation was stopped. Immediately after first resection a target sign was seen with the exposure of omental fat. Omental fat was then immediately suctioned into the caecum and it was fixed to nearby mucosa with five clips. Clips were fixed with endoloop, with complete closure of wall defect, by creation of the omental patch. Subsequently, a computed tomography (CT) scan of the whole abdomen with endovenous contrast revealed absence of pneumoperitoneum or liquid collection in the abdomen. Because of incomplete resection of the lesion and history of long-standing ulcerative colitis, patients was referred to surgeon for colectomy. Histology of the resected specimen showed low-grade dysplasia adenoma.

Conclusions:

Due to fibrosis therapeutic endoscopy in UC has a potential risk of increased adverse event, like perforation. Endoscopic closure should be considered depending on the type of perforation, size of the defect and endoscopist expertise. Clinical outcome of the patients depends on the timing and efficacy of endoscopic interventions.