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Gastrointestinal: Endoscopic management for a delayed perforation after endoscopic submucosal dissection for early gastric cancer

A 73-year-old woman was referred to our hospital for treatment of an early gastric cancer of 20-mm diameter, which was located in the anterior wall of the upper third of the stomach. The patient also had congestive heart disease and selected treatment with endoscopic submucosal dissection (ESD). ESD was performed with an insulated-tip (IT-2) knife (KD-611L; Olympus, Tokyo, Japan). The lesion was resected en bloc. There was no perforation in the artificial ulcer, and a chest radiograph showed no free air immediately after the ESD. The procedure time was 75 minutes. Ten hours after the procedure, the patient complained of abdominal pain. Abdominal computed tomography showed pneumoperitoneum. Emergent esophagogastroduodenoscopy was performed with carbon dioxide insufflation. There was a perforation, 15 mm in diameter, in the artificial ulcer (Figure 1). The perforation was closed with seven endoclips (Figure 2). The patient was treated conservatively with nothing per os, i.v. fluid, and i.v. broad-spectrum antibiotics. She had an uneventful recovery and was discharged on the 14th day after ESD. The lesion was found to be submucosal invasive carcinoma. In terms of complications during ESD for early gastric cancer, perforation occurs in about 4% to 5% of cases, which is high compared with endoscopic mucosal resection. Delayed perforation is a rare complication (0.1%–0.45%) and is presumed to arise from electrical cautery during submucosal dissection or repeated coagulation that causes ischemic change to the gastric wall, resulting in necrosis. Most perforations that occur during ESD can undergo conservative treatment by complete endoscopic closure using endoclips. When the perforation is small (<1 cm), endoscopic closure can be completed with one or two clips. If the defect is large, the endoclips should be deployed from the edge of the hole and the air in the stomach should be suctioned when the endoclip is closed. Another method for sealing large defects is an omental patch method. After the omentum is suctioned from the defect, clipping around the defect is performed. Normal or large endoclips are suitable for closure of perforations and short endoclips are suitable for hemostasis, especially for the hard base of an ulcer. However, a delayed perforation often needs emergent surgery. Hanaoka et al. reported 6 patients with delayed perforation among 1159 patients who underwent gastric ESD. Five of these patients required emergent surgery because of severe peritonitis, but one could be conservatively treated with antibiotic therapy because the peritonitis was localized. In the present case, early diagnosis and immediate endoscopic closure with endoclips enabled conservative treatment. When the time to detection of a delayed perforation is short and peritonitis is localized or the symptoms are not severe, we attempt endoscopic closure.