Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms

Background and study aims: Endoscopic submucosal dissection (ESD) is a novel technique used for the treatment of gastrointestinal neoplasia. One of its major limitations, however, is the complication of perforation.
Patients and methods: We included in our study all the cases of perforation that occurred during ESD procedures for gastrointestinal epithelial neoplasia between February 2000 and February 2005. Clinical outcomes after perforation were investigated.
Results: Perforation was experienced at 27 lesions in 27 patients (four in the esophagus, fourteen in the stomach, seven in the colon, and two in the rectum). Fibrosis under the lesions was confirmed histologically in seven patients (26 %). Immediate closure using endoclips was performed in all patients except for three asymptomatic patients in whom a stomach perforation was first noticed when free air was noticed on a radiograph the morning after the ESD procedure. Air accumulation was detected radiographically in 21 patients (78 %). The mean duration of antibiotic treatment was 6.7 days and the patients were fasted for a mean period of 5.3 days. The mean maximum body temperature was 37.3 °C, the mean white blood cell count was 9733/mm³, and the mean C-reactive protein level was 5.0 mg/dl. All the patients were discharged well from the ward after a mean time of 12.1 days after ESD, and no recurrence caused by tumor spread from the perforation occurred in any patient after a median follow-up period of 36 months (range 9 - 52 months).
Conclusion: Successful nonsurgical management after ESD complicated by perforation is a highly feasible option if intensive conservative treatments are used following immediate endoscopic closure of the perforation.

References

• 1 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 S67-S70
• 2 Gotoda T. A large endoscopic resection by endoscopic submucosal dissection procedure for early gastric cancer.  Clin Gastroenterol Hepatol. 2005;  3 S71-S73
• 3 Yamamoto H, Yahagi N, Oyama T. Mucosectomy in the colon with endoscopic submucosal dissection.  Endoscopy. 2005;  37 764-768
• 4 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 5 Yahagi N, Fujishiro M, Kakushima N. et al . Endoscopic submucosal dissection for early gastric cancer using the tip of an electro-surgical snare (thin type).  Dig Endosc. 2004;  16 34-38
• 6 Yahagi N, Fujishiro M, Imagawa A. et al . Endoscopic submucosal dissection for the reliable en bloc resection of colorectal mucosal tumors.  Dig Endosc. 2004;  16 S89-S92
• 7 Yamamoto H, Yube T, Isoda N. et al . A novel method of endoscopic mucosal resection using sodium hyaluronate.  Gastrointest Endosc. 1999;  50 251-256
• 8 Fujishiro M, Yahagi N, Kashimura K. et al . Different mixtures of sodium hyaluronate and their ability to create submucosal fluid cushions for endoscopic mucosal resection.  Endoscopy. 2004;  36 584-589
• 9 Fujishiro M, Yahagi N, Kashimura K. et al . Comparison of various submucosal injection solutions for maintaining mucosal elevation during endoscopic mucosal resection.  Endoscopy. 2004;  36 579-583
• 10 Conio M, Rajan E, Sorbi D. et al . Comparative performance in the porcine esophagus of different solutions used for submucosal injection.  Gastrointest Endosc. 2002;  56 513-516
• 11 Fujishiro M, Yahagi N, Kashimura K. et al . Tissue damage of different submucosal injection solutions for endoscopic mucosal resection.  Gastrointest Endosc. 2005;  62 933-942
• 12 Fujishiro M, Yahagi N, Nakamura M. et al . Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar.  Gastrointest Endosc. 2006;  63 243-249
• 13 Shimizu Y, Kato M, Yamamoto J. et al . Endoscopic clip application for closure of esophageal perforations caused by EMR.  Gastrointest Endosc. 2004;  60 636-639
• 14 Tsunada S, Ogata S, Ohyama T. et al . Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips.  Gastrointest Endosc. 2003;  57 948-951
• 15 Damore L J 2nd, Rantis P C, Vernava A M 3rd. et al . Colonoscopic perforations: etiology, diagnosis, and management.  Dis Colon Rectum. 1996;  39 1308-1314
• 16 Taku K, Sano Y, Fu K I. et al . Iatrogenic perforation at therapeutic colonoscopy: should the endoscopist attempt closure using endoclips or transfer immediately to surgery?.  Endoscopy. 2006;  38 428
• 17 Minami S, Gotoda T, Ono H. et al . Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video).  Gastrointest Endosc. 2006;  63 596-601
• 18 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
• 19 Gotoda T, Yanagisawa A, Sasako M. et al . Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers.  Gastric Cancer. 2000;  3 219-225
• 20 Kitajima K, Fujimori T, Fujii S. et al . Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study.  J Gastroenterol. 2004;  39 534-543
• 21 Soetikno R M, Gotoda T, Nakanishi Y. et al . Endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 567-579
• 22 Seewald S, Soehendra N. Perforation: part and parcel of endoscopic resection?.  Gastrointest Endosc. 2006;  63 602-605