Successful endoscopic closure of delayed perforation using hemoclips after colorectal endoscopic submucosal dissection

Delayed perforation following colorectal endoscopic submucosal dissection (ESD) occurs in approximately 0.4% of cases [1] [2]. Although it is rare, emergency surgery is required in nearly half of these cases [3]. Endoscopic closure for such perforations is rarely performed. No cases of successful closure of delayed perforation using hemoclips after colorectal ESD have yet been reported. Here, we present a case of delayed perforation following colon ESD that was successfully closed with hemoclips and managed conservatively.

A 44-year-old woman underwent ESD for a 45-mm tumor located in the ascending colon ([Fig. 1]). The tumor was resected en bloc without complications. However, 18 h post-procedure, she developed a fever of 38°C and experienced localized right lower abdominal pain without rebound tenderness. She was initially managed with fasting, but her fever and abdominal pain persisted until day 3. Computed tomography (CT) revealed minimal extraluminal air and fluid near the ESD site, suggestive of a micro-perforation ([Fig. 2]). Considering the mild symptoms and CT findings, emergency endoscopy was planned after consultation with surgeons.

Fig. 1 Endoscopic view. a Endoscopic view of tumor before endoscopic submucosal dissection (ESD). b No perforation or thermal damage was noted after ESD.

Fig. 2 Computed tomography showing a small amount of extraintestinal air (yellow oval) around the ulcer site after endoscopic submucosal dissection.

Colonoscopy, performed without prior bowel preparation, revealed two 5-mm perforation sites. These were closed using reopenable clips, reinforced with the less expensive hemoclips ([Fig. 3], [Video 1]). Following closure, the patient’s abdominal pain resolved promptly. Oral intake was resumed on day 6, and she was discharged on day 8. No recurrence of pain or abscess formation was noted after closure of the perforation sites.

Fig. 3 Closure of the perforation sites with hemoclips. a Two perforation sites (yellow ovals) were found in the defect created after endoscopic submucosal dissection. b, c The first perforation site was closed with a re-openable clip. d The second perforation site is seen. e Both perforation sites were completely closed using hemoclips.

Successful endoscopic closure of delayed perforation using hemoclips after colorectal endoscopic submucosal dissection.Video 1

Kuwabara et al. previously reported a case of delayed perforation after hybrid ESD that was successfully closed using an over-the-scope (OTS) clip system [4]. While the OTS clip offers robust closure, its application can be challenging in cases involving multiple perforations, as it may obstruct additional clip placements. Furthermore, large ulcers pose a risk of tearing the ulcer bed during OTS clip deployment. High costs and the inability to reposition the clip further limit its utility.

In the present case, the large ulcer size and the presence of two perforation sites made hemoclips a more suitable choice. Hemoclips provided effective closure while maintaining cost efficiency and avoiding potential complications associated with the OTS clip system.

Although the use of hemoclips is context-dependent, when the perforation site is identifiable and accessible, closure with hemoclips may avoid the need for emergency surgery at a lower cost compared to OTS clips.

Endoscopy_UCTN_Code_CPL_1AJ_2AD_3AD

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Saito Y, Uraoka T, Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
• 2 Boda K, Oka S, Tanaka S. et al. Clinical outcomes of endoscopic submucosal dissection for colorectal tumors: a large multicenter retrospective study from the Hiroshima GI Endoscopy Research Group. Gastrointest Endosc 2018; 87: 714-722
• 3 Iwatsubo T, Takeuchi Y, Yamasaki Y. et al. Differences in clinical course of intraprocedural and delayed perforation caused by endoscopic submucosal dissection for colorectal neoplasms: a retrospective study. Dig Dis 2019; 37: 53-62
• 4 Kuwabara H, Chiba H, Tachikawa J. et al. Endoscopic closure using over-the-scope clip for delayed colonic perforation after hybrid endoscopic submucosal dissection. Endoscopy 2020; 52: E368-E369

Publication History

Article published online:
14 January 2025