Endoscopic closure of delayed perforations after colorectal endoscopic submucosal
dissection (ESD) is challenging due to the fragility of the ulcer bed and the stiffness
of the surrounding tissue [1 ]
[2 ]
[3 ]
[4 ]. The case presented here illustrates closure of an ulcer bed with delayed perforation
after ESD by endoscopic mucosa-to-mucosa closure using a ring-string traction ([Fig. 1 ]; [Video 1 ]).
Fig. 1 Schematic of ring-string traction method for endoscopic mucosa-to-mucosa closure of
ulcer bed following delayed perforation after colorectal endoscopic submucosal dissection
(ESD).
Ring-string traction facilitates endoscopic clip closure to treat delayed perforation
of the ulcer bed after colorectal endoscopic submucosal dissection.Video 1
A 47-year-old woman underwent ESD for a laterally spreading tumor (0-Is+IIa, 60×53mm)
in the
transverse colon ([Fig. 2 ]
a ,b ). En bloc resection was achieved
without any adverse event during the ESD procedure ([Fig. 2 ]
c ,d ). Fever and abdominal pain occurred
40 hours later. Delayed perforation was diagnosed on the basis of free air shown on
computed
tomography. During emergency endoscopy, a pinhole-sized mural defect in the ulcer
was confirmed
([Fig. 3 ]
a ). We abandoned closure by clips because of the fragile ulcer
bed and the thickly edematous surrounding mucosa; instead we decided to use a ring-string
traction technique. To do this, a hand-made small (diameter 1 cm) ring of dental floss
(string)
was grasped with a retractable clip, drawn through the scope, and fixed to the normal
mucosa on
the anal side of the ulcer. Next, the ring-string was pulled toward the oral side
of the ulcer
with another retractable clip and likewise fixed to the normal mucosa. With two ring-string
tractions, the ulcer became narrow ([Fig. 3 ]
b ). Complete clip closure of the ulcer was then achieved ([Fig. 3 ]
c ). The patient recovered with antimicrobial treatment and was
discharged on the 7th day.
Fig. 2 Endoscopic images of lesion and ESD procedure. a Laterally spreading tumor (LST) in the transverse colon. b Chromoendoscopic view. c No perforation in the ulcer bed. d ESD was achieved without adverse events.
Fig. 3 Endoscopic images of delayed perforation and closure using ring-string traction. a Delayed perforation (40 hours after ESD) in the ulcer bed. b With traction using a ring-string fixed with retractable clips, the normal mucosa
on the anal and the oral sides of the ulcer were brought closer together. c Complete ulcer closure was achieved with clips.
In this case, ring-string traction showed two advantages. First, delivery of the device
through the scope enabled an immediate closure operation. Second, the technique is
convenient and cost-effective because it does not require specific devices. This case
suggests that ring-string traction would be useful for endoscopic closure after delayed
perforation of the ulcer bed after ESD, and could help to avoid emergent surgery.
Endoscopy_UCTN_Code_CPL_1AJ_2AD
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