Improved outcomes of endoscopic treatment for delayed perforation following endoscopic submucosal dissection for gastric epithelial neoplasms

Abstract

Background and study aims

Emergency surgery is usually required for patients with delayed perforation after gastric endoscopic submucosal dissection (ESD); however, cases of successful endoscopic treatment recently have been reported. Here, we elucidated the usefulness of endoscopic intervention for patients with delayed perforation.

Patients and methods

Patients who underwent gastric ESD from 2005 to 2022 were assessed for eligibility. Delayed perforation was defined as no intraprocedural perforation after the ESD but subsequent development of peritoneal irritation and free air on computed tomography scan. Participants were divided into early- and late-period groups based on time (October 2015) of implementation of the polyglycolic acid (PGA) sheet and the over-the-scope clip (OTSC) in clinical practice. We evaluated changes in incidence of required surgery.

Results

Among the 5,048 patients who underwent gastric ESD, delayed perforation occurred in 28 patients (0.6%, 95% confidence interval [CI] 0.4%-0.8%). Incidence of delayed perforation did not differ significantly between the early- and late-period groups (0.5% vs. 0.6%). The proportion of patients who underwent surgery was significantly smaller in the late-period group than in the early-period group (54% vs. 13%, odds ratio [OR] 0.14, 95% CI 0.02–0.83; P = 0.042); this was confirmed by multivariate analysis (adjusted OR 0.04, 95% CI 0.002–0.9; P = 0.043) after adjustment for age, sex, Charlson’s comorbidity index, tumor location, and size.

Conclusions

Endoscopic intervention using PGA sheets and OTSC was associated with a low incidence of required surgery for delayed perforation after gastric ESD and is recommended.

Keywords

Endoscopy Upper GI Tract - Endoscopic resection (ESD, EMRc, ...) - Precancerous conditions & cancerous lesions (dysplasia and cancer) stomach - Quality and logistical aspects - Performance and complications

Publikationsverlauf

Eingereicht: 14. Mai 2024

Angenommen nach Revision: 24. Oktober 2024

Accepted Manuscript online:
11. Dezember 2024

Artikel online veröffentlicht:
29. Januar 2025

• References

• 1 Ono H, Yao K, Fujishiro M. et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition). Dig Endosc 2021; 33: 4-20
• 2 Pimentel-Nunes P, Libanio D, Bastiaansen BAJ. et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022; 54: 591-622
• 3 Hanaoka N, Uedo N, Ishihara R. et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112-1115
• 4 Suzuki H, Oda I, Sekiguchi M. et al. Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection. World J Gastroenterol 2015; 21: 12635-12643
• 5 Yano T, Tanabe S, Ishido K. et al. Delayed perforation after endoscopic submucosal dissection for early gastric cancer: Clinical features and treatment. World J Gastrointest Endosc 2016; 8: 368-373
• 6 Ono H, Takizawa K, Kakushima N. et al. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015; 47: E18-E19
• 7 Takimoto K, Hagiwara A. Filling and shielding for postoperative gastric perforations of endoscopic submucosal dissection using polyglycolic acid sheets and fibrin glue. Endosc Int Open 2016; 4: E661-E664
• 8 Homma S, Tokodai K, Watanabe M. et al. Delayed perforation occurring on the 24th day after endoscopic submucosal dissection for early gastric cancer. Clin J Gastroenterol 2017; 10: 124-127
• 9 Yamamoto Y, Nishisaki H, Sakai H. et al. Clinical factors of delayed perforation after endoscopic submucosal dissection for gastric neoplasms. Gastroenterol Res Pract 2017; 2017: 7404613
• 10 Kono M, Kanesaka T, Maekawa A. et al. Delayed perforation after gastric endoscopic submucosal dissection can be treated by using over-the-scope clips. Ann Gastroenterol 2019; 32: 526
• 11 Takimoto K, Matsuura N, Nakano Y. et al. Efficacy of polyglycolic acid sheeting with fibrin glue for perforations related to gastrointestinal endoscopic procedures: a multicenter retrospective cohort study. Surg Endosc 2022; 36: 5084-5093
• 12 Kim TS, Min BH, Min YW. et al. Delayed perforation occurring after gastric endoscopic submucosal dissection: Clinical features and management strategy. Gut Liver 2023; 15: 40-49
• 13 Ishihara R, Iishi H, Uedo N. et al. Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest Endosc 2008; 68: 1066-1072
• 14 Fujimoto K, Fujishiro M, Kato M. et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc 2014; 26: 1-14
• 15 Kato M, Uedo N, Hokimoto S. et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants. Dig Endosc 2018; 30: 433-440
• 16 Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer 2011; 14: 101-112
• 17 Yamamoto Y, Kikuchi D, Nagami Y. et al. Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts. Dig Endosc 2019; 31: 4-20
• 18 Kouketsu A, Shimizu Y, Nogami S. et al. Wound healing effect of autologous fibrin glue and polyglycolic acid sheets in a rat back skin defect model. Transfus Apher Sci 2021; 60: 103144
• 19 Kirschniak A, Kratt T, Stuker D. et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc 2007; 66: 162-167
• 20 Voermans RP, Le Moine O, von Renteln D. et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol 2012; 10: 603-608
• 21 Watari J, Tomita T, Toyoshima F. et al. The incidence of "silent" free air and aspiration pneumonia detected by CT after gastric endoscopic submucosal dissection. Gastrointest Endosc 2012; 76: 1116-1123
• 22 Cho SJ, Choi IJ, Kim SJ. et al. Clinical significance of intraperitoneal air on computed tomography scan after endoscopic submucosal dissection in patients with gastric neoplasms. Surg Endosc 2014; 28: 307-313
• 23 Rodrigues-Pinto E, Repici A, Donatelli G. et al. International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks. Endosc Int Open 2019; 7: E1671-E1682