Differences in Clinical Course of Intraprocedural and Delayed Perforation Caused by Endoscopic Submucosal Dissection for Colorectal Neoplasms: A Retrospective Study

Abstract

Background: Although the use of endoscopic submucosal dissection (ESD) as a minimally invasive treatment for large superficial colorectal neoplasms is increasing, colorectal ESD remains technically challenging. As perforation in the colorectum is generally considered to be associated with a higher risk of complications, the aim of this study was to investigate the characteristics of perforation caused by colorectal ESD. Methods: This retrospective study included 635 lesions treated with colorectal ESD, between February 2011 and December 2015, in a tertiary cancer center. We evaluated and compared the clinical course and short-term outcomes of the intraprocedural perforation group with those of the delayed perforation and no perforation groups. Results: Perforation occurred in 45 (7.1%) of the 635 cases. Thirty-six cases were intraprocedural perforation (5.7%), all of which were successfully closed with endoclips during the procedure. Nine cases of delayed perforation occurred (1.4%). No emergency surgery was performed in the intraprocedural perforation group; however, 5 of 9 cases underwent emergency surgery in the delayed perforation group (56%, p < 0.0001). There were statistically significant differences between the intraprocedural and delayed perforation groups with regard to the hospitalization period, fasting period, abdominal pain scale, peak white blood cell (WBC) count, and peak C-reactive protein (CRP), and between the intraprocedural and no perforation groups with regard to the location of the lesion, hospitalization period, fasting period, abdominal pain scale, peak WBC, peak CRP, and en bloc resection rate. Conclusions: While intraprocedural perforation due to colorectal ESD can be managed conservatively, delayed perforation can lead to serious adverse events.

Feasibility of underwater endoscopic mucosal resection and management of residues for superficial non‐ampullary duodenal epithelial neoplasms

“…There was a similar discussion for colorectal ESD, which has been one of the standard procedures for large colorectal lesions in Japan. ESD for SNADEN is not widely used at present, even in Japan, because the incidence and severity of adverse events are less in duodenal ESD than in colorectal ESD . Moreover, the accuracy of pathological diagnosis of piecemeal resection is worse than for en bloc resection.…”

“…Delayed bleeding was defined as bleeding requiring presentation to the emergency department, hospitalization, or medical intervention. Delayed perforation was defined as perforation occurring after the ER procedure, accompanied by free air or liquid as detected by computed tomography or radiography, in the absence of any symptom or identification of perforation immediately after the ER procedure …”

Delayed perforation after endoscopic resection of a colonic laterally spreading tumor: A case report and literature review

“…Endoscopic perforation is classified as intraoperative and delayed perforation; the latter is even rarer, with reported rates of 0.3%-0.7%[ 7 ] and is defined as perforation within 48 h after endoscopic surgery. All previously reported ten cases occurred within 48 h after ESD or EMR[ 8 - 12 ], accompanied by peritonitis of various degrees. Delayed perforation in our case took place in 15 h and caused progressively increasing peritonitis, which is even rarer because of the aggravating peritonitis and our earlier recognition compared with previous case reports.…”

“…Currently, there are no guidelines on the management of delayed perforation after colonic endoscopic resection. Delayed perforation after therapeutic colonoscopy is a rare event; however, it is severe, and emergent surgery is the most common treatment for this situation, especially in the context of peritonitis[ 12 ]. With the development of endoscopic techniques[ 11 , 16 - 19 ], timely endoscopic closure may be a good option, if delayed perforation occurs in the patient’s fasting period with local peritonitis.…”

“…In the English literature, only five other reports (10 cases) of delayed perforation after EMR and ESD with non-surgical management have been reported[ 8 - 12 ] (Table 1 ). The decision to conduct an endoscopic operation also depends on the perforation size, endoscopist’s experience, and instruments available[ 2 , 15 , 20 - 23 ].…”