Clip-induced esophageal perforation during endoscopic submucosal dissection: the perfect is the enemy of the good!

Superficial muscular injury without deep perforation frequently occurs during endoscopic submucosal dissection (ESD) of superficial neoplasms. The optimum management of this not uncommon situation is unclear. Clipping could avoid secondary perforation and postresection coagulation syndrome.

Here we report a case in which thermal muscular damage occurred during ESD of a squamous cell carcinoma of the upper third of the esophagus due to severe submucosal fibrosis. The damaged area was around 5  ×  5 mm. Clipping was performed to prevent infectious complications because oral corticosteroid was indicated to prevent stenosis after 75 % circumferential resection. However, the clipping caused a deep tear of the muscular layer ([Video 1], [Fig. 1]), with visualization of the periesophageal fat secondary to the first clip.

Video 1 Esophageal perforation due to clipping.

Fig. 1 Esophageal perforation due to clipping.

The clip was removed using a 10-mm polypectomy snare. A complete 3-mm perforation was confirmed and efficiently closed using an Ovesco clip.

In cases of muscle damage without transmural perforation, the risk–benefit ratio of closure with standard clips must be assessed. If closure is performed, aggravation of the lesion should be avoided. Misplaced clips can be removed using a polypectomy snare, enabling treatment of the complication using suitable methods.

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