A 78-year-old man underwent total colonoscopy because of positive
fecal occult blood test. Two lateral spreading tumors (LST), approximately
35 mm and 40 mm in size, were detected in the cecum and
transverse colon, respectively. Both lesions were endoscopically diagnosed as
adenoma or focal cancer in adenoma, and therefore considered good candidates
for endoscopic resection.
Initially, endoscopic submucosal dissection (ESD) was attempted for
en bloc resection of the LST located in the cecum. During the procedure,
although no definite perforation was recognized, the patient became aware of
marked abdominal distension, and then developed hypotension, his blood pressure
decreasing to 80 mm Hg. The procedure was immediately
discontinued, and emergency abdominal computed tomography (CT) demonstrated a
large pneumoperitoneum with collapse of the inferior vena cava ([Fig. 1]). Paracentesis was performed for
decompression with a 20 gauge puncture needle. The patient’s symptoms
were relieved, and the blood pressure and diameter of the inferior vena cava
returned to normal immediately after decompression. The patient recovered
uneventfully after conservative treatment, including withholding oral intake,
intravenous administration of antibiotics, and hyperalimentation.
Fig. 1 Abdominal computed
tomography showed a large pneumoperitoneum causing collapse of the inferior
vena cava.
In order to completely remove large colorectal tumors endoscopically
en bloc, a novel technique of ESD instead of conventional endoscopic mucosal
resection (EMR) has been developed [1]. This technique is
reportedly associated with a significant incidence of complications, such as
perforation and bleeding, in comparison with conventional EMR
[1]
[2]. However, most perforations
that occur during ESD are small and can be managed conservatively with endoclip
placement if recognized immediately. In the present case, the exact site of
perforation, which may have been a mini-perforation, could not be detected
endoscopically, and thus pressurized air resulted in increased intra-abdominal
pressure. In general, increased intra-abdominal pressure can have numerous
adverse physiologic effects, which may include decreased venous return,
decreased cardiac output, and altered ventilation-perfusion relationships
[3]
[4]. Tension pneumoperitoneum
should be suspected in all patients who develop circulatory and/or respiratory
collapse with acute abdominal distension during or after endoscopy, especially
for treatments that carry a high risk of perforation [3].
Early identification and prompt treatment with needle decompression are
important in order to avoid serious sequelae such as abdominal compartment
syndrome leading to multiple organ failure [4].
Acknowledgment
This work was supported in part by the Grant-in-Aid for Cancer
Research (18S-2, H18 – 005) from the Ministry of Labour and
Welfare.
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