Endoscopy 2010; 42(1): 8-14
DOI: 10.1055/s-0029-1215215
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Pneumomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection

Y.  Tamiya1 , K.  Nakahara1 , K.  Kominato1 , O.  Serikawa1 , Y.  Watanabe1 , H.  Tateishi1 , H.  Takedatsu1 , A.  Toyonaga2 , M.  Sata1
  • 1Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
  • 2Yasumoto Hospital, Fukuoka, Japan
Further Information

Publication History

submitted 24 June 2009

accepted after revision 31 August 2009

Publication Date:
06 November 2009 (online)

Background and study aim: Esophageal perforation caused by endoscopic submucosal dissection (ESD) induces serious pneumomediastinum. In the absence of endoscopically detected perforation, postprocedural pneumomediastinum may occur. The aim of this study was to evaluate the association between the clinical factors/courses and pneumomediastinum revealed by chest computed tomography (CT) with special reference to an exposed muscle layer during esophageal ESD.

Patients and methods: A total of 58 patients undergoing ESD for esophageal neoplasms between February 2003 and June 2007 also underwent both chest radiography and chest CT within 1 hour after ESD. We studied the association between findings on CT scan and tumor-related and technical factors of esophageal ESD by uni- and multivariate analyses. We also analyzed the clinical factors/courses experienced by all patients.

Results: Pneumomediastinum was detected in 18 / 58 patients (31 %) by chest CT compared with only 1 / 58 patients (1.7 %) by chest radiography. ESD-induced exposure of the muscular layer (32 patients) was the only significant factor for pneumomediastinum (18 / 32; P < 0.0001). Clinical factors such as fever, white blood cell count, and C-reactive protein were significantly increased in the group positive for both endoscopically exposed muscular layer and pneumomediastinum (+/+, n = 18) compared with the (–/–) group (n = 26) in the early phase (day 1) after ESD. However, these factors did not affect the length of the fasting period or the length of hospital stay.

Conclusions: In esophageal ESD, pneumomediastinum detected by chest CT only does not cause clinically significant complication. Endoscopic muscle exposure during ESD is a significant risk factor for pneumomediastinum, which causes mild inflammation in the early post-ESD phase.

References

  • 1 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 67-70
  • 2 Oyama T, Tomori A, Hotta K. et al . ESD with a hook knife for early esophageal cancer [article in Japanese with English abstract].  Stomach and Intestine. 2006;  41 491-497
  • 3 Fujishiro M, Yahagi N, Kakushima N. et al . Endoscopic submucosal dissection of esophageal squamous cell neoplasms.  Clin Gastroenterol Hepatol. 2006;  4 688-694
  • 4 Yamamoto H, Kawata H, Sunada K. et al . Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood.  Endoscopy. 2003;  35 690-694
  • 5 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
  • 6 Gotoda T, Yamamoto H, Soettikno R. Endoscopic submucosal dissection of gastric cancer.  J Gastroenterol. 2006;  41 929-942
  • 7 Fujishiro M, Yahagi N, Nakamura N. et al . Endoscopic submucosal dissection for rectal epithelial neoplasia.  Endoscopy. 2006;  38 493-497
  • 8 Katada C, Muto M, Manabe T. et al . Local recurrence of squamous-cell carcinoma of the esophagus after EMR.  Gastrointest Endosc. 2005;  61 219-225
  • 9 Natsugoe S, Baba M, Yoshinaka H. et al . Mucosal squamous cell carcinoma of the esophagus: a clinicopathologic study of 30 cases.  Oncology. 1998;  55 235-241
  • 10 Tajima Y, Nakanishi Y, Ochiai A. et al . Histopathologic findings predicting lymph node metastasis and prognosis of patients with superficial esophageal carcinoma: analysis of 240 surgically resected tumors.  Cancer. 2000;  88 1285-1293
  • 11 Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the upper GI tract – hook knife EMR method.  Minim Invasive Ther Allied Technol. 2002;  11 291-295
  • 12 Japanese Society for Esophageal Disease .Guidelines for clinical and pathologic studies on carcinoma of the esophagus [article in Japanese with English abstract in part]. 10th edn. Tokyo; Kanehara Shuppan 2007
  • 13 Fujishiro M, Yahagi N, Kakushima N. et al . Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms.  Endoscopy. 2006;  38 1001-1006
  • 14 Simizu Y, Kato M, Yamamoto J. et al . Endoscopic clip application for closure of esophageal perforations caused by EMR.  Gastrointest Endosc. 2004;  60 636-639
  • 15 Kakushima N, Yahagi N, Fujishiro M. et al . Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction.  Endoscopy. 2006;  38 170-174
  • 16 Yamamoto H, Kawata H, Sunada K. et al . Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate.  Gastrointest Endosc. 2002;  56 507-512
  • 17 Fujishiro M, Yahagi N, Kakushima N. et al . Comparison of various submucosal injection solutions for maintaining mucosal elevation during endoscopic mucosal resection.  Endoscopy. 2004;  36 579-583
  • 18 Fujishiro M, Yahagi N, Kakushima N. et al . Different mixtures of sodium hyaluronate and their ability to create submucosal fluid cushions for endoscopic mucosal resection.  Endoscopy. 2004;  36 584-589

Y. TamiyaMD 

Division of Gastroenterology
Department of Medicine
Kurume University School of Medicine

67 Asahi-machi
Kurume
Fukuoka
830-0011 Japan

Fax: +81-942-342623

Email: tamiya_yoshitaka@kurume-u.ac.jp