A 75-year-old woman with epigastric pain was referred to our center
for removal of a polypoid lesion in the stomach. Esophagogastroduodenoscopy
revealed a 25-mm semipedunculate, polypoid, multilobular lesion at the small
gastric curve. Histopathological examination showed that the lesion was a
moderately differentiated adenocarcinoma with invasion of the muscularis mucosa
([Fig. 1]).
Fig. 1 a, b The biopsy
specimen showing a moderately differentiated adenocarcinoma (hematoxylin and
eosin, magnification × 40).
Abdominal tomography confirmed a 2-cm thickening of the gastric
walls without extraperitoneal extension. Endoscopic ultrasound showed the
lesion to be 33 × 22 mm in size, mobile, and
inhomogeneous, with no infiltration of the muscularis propria.
Endoscopic mucosectomy resection (EMR) was carried out
[1]
[2]
[3]
after identifying and marking the lesion with circumferential
electrocoagulation. Following infiltration of hydroxyethyl starch in sodium
chloride (Voluven, Fresenius Kabi Italia S. p. A., Verona, Italy)
and epinephrine (1 : 20 000, 20 mL) the mucosa was
lifted from the submucosa [4]. The lesion was removed by
piecemeal technique, using a diathermic snare. Hemostasis was obtained with
electrocoagulation and injection of epinephrine
(1 : 20 000). On the first postoperative day gaseous
abdominal distension was observed with no clinical evidence of perforation.
Abdominal radiographs confirmed the presence of abundant intraperitoneal free
air and the diaphragm was raised. The patient had severe abdominal pain, but
there was no fever and no signs of peritonitis. The abdominal distension and
pain persisted throughout the second postoperative day.
Microperforations can occur during EMR, with the high pressure in
the stomach facilitating the passage of air into the abdominal cavity. However,
microperforations cannot be managed with endoscopic metal clipping because they
cannot be seen [5]. We decided to carry out air
extraction with intraperitoneal placement of a Verress needle ([Fig. 2]) in the right hypochondrium in the peritoneal
cavity, following the same technique as used during laparoscopic
cholecystectomy.
Fig. 2 The Verress needle.
This resulted in instantaneous outflow of air and an immediate and
marked improvement in the patient’s symptoms.
Our case confirms that the presence of free air does not affect the
management or the clinical outcome of microperforations and that a simple
device such as the Verress needle can be used with immediate benefit and
without any risks.
Endoscopy_UCTN_Code_TTT_1AO_2AG
Endoscopy_UCTN_Code_TTT_1AO_2AN
