Successful conservative management of a delayed perforation following gastric endoscopic submucosal dissection

An early gastric cancer was found on the gastric body in an 85-year-old man. Subsequently, an endoscopic submucosal dissection (ESD) was performed ([Fig. 1], [Video 1]). Although the muscle tissue in the post-ESD ulcer was injured, the ulcer closure was incomplete. The 20-mm lesion was resected en bloc in a 48-mm specimen. On postoperative day 1, the patient complained of epigastric pain and vomiting. Although the physical examination revealed no rebound tenderness, blood tests revealed a high white blood cell count. Computed tomography showed free air and inflammation of intra-abdominal fat in the area adjacent to the stomach ([Fig. 2], arrow). Endoscopy revealed a 15-mm diameter floating black area inside the post-ESD ulcer ([Fig. 3]). This area was diagnosed as a post-ESD perforation and its closure was attempted using an over-the-scope clip and reopenable endoclips with minimum carbon dioxide insufflation. Considering the fragile tissue around the perforation, the over-the-scope clip was deployed on the edge of the perforation. The perforation narrowed and was completely closed using seven additional endoclips ([Fig. 4]). After consulting the surgeons, we selected conservative management because of the patient’s stability. On postoperative day 6, the post-ESD ulcer was reinforced with polyglycolic acid sheets and fibrin glue ([Fig. 5]). The patient resumed eating on postoperative day 8 and was discharged on postoperative day 12. Histopathologically, the resected specimen showed a well-differentiated adenocarcinoma confined to the shallow submucosa with negative margins.

Fig. 1 Endoscopy shows the post-resected ulcer without perforation after endoscopic submucosal dissection (ESD) for early gastric cancer.

Video 1 Successful clip closure for a delayed perforation after gastric endoscopic submucosal dissection.

Fig. 2 Computed tomography, taken on postoperative day 1, shows free air and inflammation (arrow) in the adjacent area of the stomach.

Fig. 3 Endoscopy shows a perforation inside the post-ESD ulcer.

Fig. 4 The perforation was closed by endoclips.

Fig. 5 On postoperative day 6, the post-ESD ulcer was reinforced using polyglycolic acid sheets and fibrin glue.

Delayed perforation after gastric ESD is an extremely rare complication and is often managed surgically [1] [2]. However, several cases of endoscopically managed post-ESD perforations have been reported [1] [2] [3] [4] [5]. Polyglycolic acid sheets shielding alone or combined with a clip for closure are useful strategies for managing delayed perforation in the gastrointestinal tract [4] [5]. If a post-ESD perforation is endoscopically closed with a stable general condition, it might be managed conservatively.

Endoscopy_UCTN_Code_TTT_1AO_2AG

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Hanaoka N, Uedo N, Ishihara R. et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112-1115
• 2 Yamamoto Y, Kikuchi D, Nagami Y. et al. Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts. Dig Endosc 2019; 31 S1: 4-20
• 3 Ikezawa K, Michida T, Iwahashi K. et al. Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer. Gastric Cancer 2012; 15: 111-114
• 4 Ono H, Takizawa K, Kakushima N. et al. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015; 47: E18-E19
• 5 Takimoto K, Matsuura N, Nakano Y. et al. Efficacy of polyglycolic acid sheeting with fibrin glue for perforations related to gastrointestinal endoscopic procedures: A multicenter retrospective cohort study. Surg Endosc 2022; 36: 5084-5093

Publication History

Article published online:
12 June 2023