Delayed perforation after endoscopic submucosal dissection for early gastric cancer: Clinical features and treatment

Abstract

Perforation is an important procedural complication of endoscopic submucosal dissection (ESD) for early gastric cancer. Although the incidence of delayed perforation after ESD is low, extreme caution is necessary because many cases require surgical intervention. Among 1984 lesions of early gastric cancer treated in our hospital by ESD in 1588 patients from September 2002 through March 2015, delayed perforation developed in 4 patients (4 lesions, 0.25%). A diagnosis of delayed perforation requires prompt action, including surgical intervention when required.

Keywords: Delayed perforation; Early gastric cancer; Endoscopic submucosal dissection.

Figure 1

Endoscopic submucosal dissection. A: Findings on upper gastrointestinal endoscopy (conventional examination). Patient 2 had delayed perforation after undergoing endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). 0-IIc lesions were found in the anterior and posterior walls of the greater curvature at the gastric angle (circles); B: Findings after ESD. Patient 2 had delayed perforation after ESD for EGC. The 2 lesions were adjacent. The ulcer floor had fused together.

Figure 2

Radiography and abdominal computed tomography. A: A chest radiograph, showing free air below the right diaphragm (arrow); B: An abdominal computed tomography scan, showing free air (arrow).

Figure 3

Muscular layer had become necrotic. A: The surgically resected specimen. Although no distinct site of perforation was found in the surgically resected specimen, the ulcer floor had become thin after endoscopic submucosal dissection (circled); B: The histopathological specimen stained with hematoxylin and eosin. At the ulcer floor, the muscular layer was exposed, and all layers had become necrotic.