The efficacy and safety of prophylactic closure for a large mucosal defect after colorectal endoscopic submucosal dissection

Abstract

Endoscopic submucosal dissection (ESD) is not a common treatment for colorectal neoplasms because of its technical difficulties and has a higher incidence of complication. In particular, perforation is one of the severe complications and these patients require surgical intervention. However, whether prophylactic closure after colorectal ESD prevents perforation and other complications is not known. In the present study, we assessed the efficacy and safety of prophylactic closure for a large mucosal defect after colorectal ESD using a conventional clip and over-the-scope clip (OTSC) system. From April 2010 to December 2012, 68 patients with colorectal tumors were treated with ESD. The prohylactic closure was indicated for patients with excessive coagulation in the muscularis propria or larger resection size. The closure group reduced the peritoneal inflammatory reaction and abdominal symptoms without increasing complications. The closure group also had a significantly lower WBC count (post operative day 1), CRP (post operative day 4) and abdominal pain after colorectal ESD compared to the non-closure group. Perforation occurred in 1 case, and postoperative bleeding in 2 cases, with only 1 bleeding case needing an emergency endoscopy in the non-closure group. One perforation case needed emergency surgery because the endoscopic treatment was ineffective. Without increasing adverse effects, the prophylactic closure efficiently reduced the inflammatory reaction and abdominal symptoms of colorectal ESD in patients with large superficial colorectal neoplasms.

Untitled

“…Frequent use of electrocautery with an electrosurgical knife due to submucosal fibrosis could cause excessive heating of the muscular layer, and transmural burn syndrome may be more likely to occur in patients with fibrosis than in those without fibrosis. Previous retrospective studies have reported that PCC of mucosal defects after EMR and ESD significantly decreased the frequency of AEs, such as fever and abdominal pain [14,15]. In this study, although the resected specimen size and circumference of ESD ulcers in the group with complete PCC had a tendency to be smaller than those in the group with incomplete PCC, univariate analysis of AEs in this study likewise found the frequency of AEs to be higher in the group with incomplete PCC.…”

“…No AEs (n = 182) P value Regarding to delayed bleeding, reportedly, PCC after EMR or ESD decreases it [14,15]. However, in this study, no significant difference was observed in the frequency of delayed bleeding in the subgroup analysis of resected specimen size of < 40 mm between the group with complete PCC and the group with incomplete PCC.…”

Feasibility of Underwater Clip Closure for Large Mucosal Defects after Colorectal Endoscopic Submucosal Dissection

“…To avoid such delayed adverse events, prophylactic complete closure of the mucosal defect after C-ESD has been attempted by some operators, and the possibility that it may decrease delayed adverse events has been reported [6][7][8][9][10][11]. Conventional clip closure has been used most frequently and is an effective technique, but the size of the mucosal defect is limited, resulting in incomplete closure in several cases [6][7][8].…”

“…Conventional clip closure has been used most frequently and is an effective technique, but the size of the mucosal defect is limited, resulting in incomplete closure in several cases [6][7][8]. Especially, mucosal defects of > 40 mm tended to have incomplete closure [8].…”

Simple but reliable endoscopic sliding closure with ring-shaped surgical thread after endoscopic submucosal dissection

“…Although several reports have suggested that the inflammation after endoscopic submucosal dissection (ESD) of the colon can be reduced by closure of the ulcer [1,2], a simpler and more reliable closure has not been reported for ulcers over 6 cm in diameter.…”