Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer

Abstract

Perforation is a major complication of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). However, there have been no reports on delayed perforation after ESD for EGC. We aimed to elucidate the incidence and outcomes of delayed perforation after ESD. Clinical courses in 1159 consecutive patients with 1329 EGCs who underwent ESD were investigated. Delayed perforation occurred in six patients (0.45 %). All these patients had complete en bloc resection without intraoperative perforation during ESD. Five of six perforations were located in the upper third of the stomach, while one lesion was found in the middle third. Symptoms of peritoneal irritation with rebound tenderness presented within 24 h after ESD in all cases. One patient did not require surgery because the symptoms were localized, and recovered with conservative antibiotic therapy by nasogastric tube placement. The remaining five patients required emergency surgery. There was no mortality in this case series.

Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer

“…A summary of the clinicopathological features and clinical outcomes of 9 patients with delayed perforation after ESD (8 in previous reports [4][5][6] and our patient) is shown in Table 1. The mean time required for ESD in the five patients who received surgery was 3.6 h (range 1.5-9 h) and all of them had had sudden appearance of symptoms of peritoneal irritation.…”

“…Whereas perforations during ESD are usually tear-like shape, the shape of the delayed perforation was round and the color of the surrounding muscle layer had become whitish, suggesting necrosis of the muscle layer related to the delayed perforation. The mechanism of delayed perforation is thought to be due to electrical cautery during submucosal dissection or repeated coagulation that causes ischemic change to the gastric wall resulting in necrosis [4]. But in our patient, shrinkage or disappearance of a vessel penetrating the gastric wall, caused by electrical cautery, might also have led to a small perforation, combined with necrosis of the surrounding muscle layer, because the size of the perforation was small and its location appeared to be coincident with that of the vessel coagulated during the ESD.…”

“…The risk of perforation during ESD is about 4% [1] and such a perforation can be conservatively treated by complete endoscopic closure [2]. In contrast, delayed perforation is a rare complication (0.1-0.45%) which occurs 1-2 days after the procedure, but often requires emergent surgery [3,4]. Here, we report a patient with delayed perforation and provide endoscopic images of the perforation, as well as discussing the mechanism and management of this complication.…”

Recent Advances in Endoscopic and Laparoscopic Management of Gastric Malignancy: A Literature Review

“…ESD has been accepted as a minimally invasive method for local resection for EGC with a negligible risk of lymph node metastasis [3] (Table 1). Although ESD is much less invasive than conventional open gastrectomy, complications have been reported to include hemorrhage in 5.5% of patients and delayed perforation in 0.45% [10,11].…”

Endoscopic submucosal dissection and endoscopic mucosal resection for early stage esophageal cancer

“…Delayed perforation due to artificial ulcer after esophageal ESD is rare but may result in severe or even life-threatening conditions like mediastinal emphysema or mediastinitis (50). Early recognition and subsequent surgical management are essential.…”