Delayed perforation following colorectal endoscopic submucosal dissection (ESD) occurs
in approximately 0.4% of cases [1]
[2]. Although it is rare, emergency surgery is required in nearly half of these cases
[3]. Endoscopic closure for such perforations is rarely performed. No cases of successful
closure of delayed perforation using hemoclips after colorectal ESD have yet been
reported. Here, we present a case of delayed perforation following colon ESD that
was successfully closed with hemoclips and managed conservatively.
A 44-year-old woman underwent ESD for a 45-mm tumor located in the ascending colon
([Fig. 1]). The tumor was resected en bloc without complications. However, 18 h post-procedure,
she developed a fever of 38°C and experienced localized right lower abdominal pain
without rebound tenderness. She was initially managed with fasting, but her fever
and abdominal pain persisted until day 3. Computed tomography (CT) revealed minimal
extraluminal air and fluid near the ESD site, suggestive of a micro-perforation ([Fig. 2]). Considering the mild symptoms and CT findings, emergency endoscopy was planned
after consultation with surgeons.
Fig. 1 Endoscopic view. a Endoscopic view of tumor before endoscopic submucosal dissection (ESD). b No perforation or thermal damage was noted after ESD.
Fig. 2 Computed tomography showing a small amount of extraintestinal air (yellow oval) around
the ulcer site after endoscopic submucosal dissection.
Colonoscopy, performed without prior bowel preparation, revealed two 5-mm perforation
sites. These were closed using reopenable clips, reinforced with the less expensive
hemoclips ([Fig. 3], [Video 1]). Following closure, the patient’s abdominal pain resolved promptly. Oral intake
was resumed on day 6, and she was discharged on day 8. No recurrence of pain or abscess
formation was noted after closure of the perforation sites.
Fig. 3 Closure of the perforation sites with hemoclips. a Two
perforation sites (yellow ovals) were found in the defect created after endoscopic
submucosal dissection. b, c The first perforation site was closed
with a re-openable clip. d The second perforation site is seen.
e Both perforation sites were completely closed using
hemoclips.
Successful endoscopic closure of delayed perforation using hemoclips after colorectal
endoscopic submucosal dissection.Video 1
Kuwabara et al. previously reported a case of delayed perforation after hybrid ESD
that was successfully closed using an over-the-scope (OTS) clip system [4]. While the OTS clip offers robust closure, its application can be challenging in
cases involving multiple perforations, as it may obstruct additional clip placements.
Furthermore, large ulcers pose a risk of tearing the ulcer bed during OTS clip deployment.
High costs and the inability to reposition the clip further limit its utility.
In the present case, the large ulcer size and the presence of two perforation sites
made hemoclips a more suitable choice. Hemoclips provided effective closure while
maintaining cost efficiency and avoiding potential complications associated with the
OTS clip system.
Although the use of hemoclips is context-dependent, when the perforation site is identifiable
and accessible, closure with hemoclips may avoid the need for emergency surgery at
a lower cost compared to OTS clips.
Endoscopy_UCTN_Code_CPL_1AJ_2AD_3AD
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