Clinical Course of Intraprocedural Perforation Caused by Gastric and Colorectal Endoscopic Submucosal Dissection

Aims Although endoscopic submucosal dissection (ESD)is a minimally invasive treatment for gastrointestinal digestion, perforation is generally considered to be associated with a higher risk of complications. While some cases can be treated conservatively, others require drainage or surgical treatment. The aim of this study was to investigate the factors that influence the clinical course after perforation during gastric and colorectal ESD.

Methods During the period from 2021 to 2023, we performed ESD procedures on a total of 3251 cases, including gastric 1971 cases and colorectal 1280 cases. Among these cases, perforation occurred in 43 instances (1.3%). We conducted a retrospective comparative study, categorizing the cases into two groups based on the manifestation of symptoms: the symptomatic group (with symptoms such as body temperature≥37.5 degrees or Numerical Rating Scale≥5 abdominal pain) and the asymptomatic group.

Results In all cases, the perforation was closed with a clip and ESD was completed. 42/43(98%) could be treated conservatively. In the symptomatic group (n=16) compared to the asymptomatic group (n=27), there were no significant differences in age (72.8 vs. 70.7 years, p=0.39), male-to-female ratio (6 (38%) vs. 12 (44%), p=0.659), resection specimen size (52.9 (15-115) mm vs. 41.1 (16-80) mm, p=0.29), lesion size (40.7 (12-110) mm vs. 31.0 (12-70) mm, p=0.29), ESD procedure time (100.6 (10-200) min vs. 81.2 (7-170) min, p=0.30), perforation size (2.3 (1-10) mm vs. 1.3 (1-2) mm, p=0.86), and macroscopic type (nodular type lesion: flat lesion) (2:14 vs. 5:22, p=0.49). In all cases of perforation during ESD, successful closure using clips was achieved, allowing completion of the ESD procedure. The time required for perforation closure was significantly longer in the symptomatic group compared to the asymptomatic group (46.6 (6-129) min vs. 12.3 (2-36) min, p<0.01). The white blood cell count was higher in the symptomatic group (10956 (5900-21300)/μl vs. 8562 (4500-15200)/μl, p=0.03). Furthermore, the symptomatic group had a longer duration until the initiation of postoperative diet (2.8 (1-6) days vs. 1.9 (1-6) days, p=0.03) and a prolonged hospital stay until discharge (6.2 (4-16) days vs. 4.0 (2-7) days, p<0.01). Only one case in the symptomatic group required surgical treatment for perforation. One case in the symptomatic group that required surgery was due to worsening peritonitis. [1] [2]

Conclusions The time required for closure of the perforation affected the appearance of postoperative symptoms. In intraoperative perforation, it is important to close the perforation site in the shortest possible time for a good clinical course.

Publication History

Article published online:
15 April 2024

• References

• 1 Iwatsubo T. et al. Differences in Clinical Course of Intraprocedural and Delayed Perforation Caused by Endoscopic Submucosal Dissection for Colorectal Neoplasms: A Retrospective Study. Dig Dis 2019; 37 (01) 53-62
• 2 Hotta K, Shinohara T, Oyama T. et al. Criteria for non-surgical treatment of perforation during colorectal endoscopic submucosal dissection. Digestion 2012; 85 (02) 116-20