Improved outcomes of endoscopic treatment for delayed perforation following endoscopic submucosal dissection for gastric epithelial neoplasms

Abstract

Background and study aims: Emergency surgery is usually required for patients with delayed perforation after gastric endoscopic submucosal dissection (ESD); however, cases of successful endoscopic treatment recently have been reported. Here, we elucidated the usefulness of endoscopic intervention for patients with delayed perforation.

Patients and methods: Patients who underwent gastric ESD from 2005 to 2022 were assessed for eligibility. Delayed perforation was defined as no intraprocedural perforation after the ESD but subsequent development of peritoneal irritation and free air on computed tomography scan. Participants were divided into early- and late-period groups based on time (October 2015) of implementation of the polyglycolic acid (PGA) sheet and the over-the-scope clip (OTSC) in clinical practice. We evaluated changes in incidence of required surgery.

Results: Among the 5,048 patients who underwent gastric ESD, delayed perforation occurred in 28 patients (0.6%, 95% confidence interval [CI] 0.4%-0.8%). Incidence of delayed perforation did not differ significantly between the early- and late-period groups (0.5% vs. 0.6%). The proportion of patients who underwent surgery was significantly smaller in the late-period group than in the early-period group (54% vs. 13%, odds ratio [OR] 0.14, 95% CI 0.02-0.83; P = 0.042); this was confirmed by multivariate analysis (adjusted OR 0.04, 95% CI 0.002-0.9; P = 0.043) after adjustment for age, sex, Charlson's comorbidity index, tumor location, and size.

Conclusions: Endoscopic intervention using PGA sheets and OTSC was associated with a low incidence of required surgery for delayed perforation after gastric ESD and is recommended.

Keywords: Endoscopic resection (ESD, EMRc, ...); Endoscopy Upper GI Tract; Performance and complications; Precancerous conditions & cancerous lesions (dysplasia and cancer) stomach; Quality and logistical aspects.

Fig. 1

Selection flow of the study participants. CT, computed tomography; ESD, endoscopic submucosal dissection.

Fig. 2

Clinical outcomes of the patients with delayed perforation. OTSC, over-the-scope clip; PGA, polyglycolic acid.

Fig. 3

Endoscopic images of the case of delayed perforation treated using a polyglycolic acid (PGA) sheet. a A 20-mm tumor located in the greater curvature of the upper body of the operated stomach after distal gastrectomy by Billroth I anastomosis. b The tumor was removed by endoscopic submucosal dissection (ESD) without intraoperative perforation. c The patient had epigastric pain 1.5 hours after ESD. Computed tomography showed free air. d Endoscopy revealed a 5-mm muscle defect in the post-ESD ulcer (yellow head). e The perforation was closed using a PGA sheet (yellow head). f After 2 months, the post-ESD ulcer was healed, including the perforation.

Fig. 4

Endoscopic images of the case of delayed perforation treated using an over-the-scope clip (OTSC). a A tumor located in the greater curvature of the upper body of the operated stomach after distal gastrectomy by Billroth I anastomosis. The tumor was unclear in the biopsy in the previous endoscopic examination. Thus, the marking was performed around the biopsy scar. b The tumor was removed by endoscopic submucosal dissection (ESD) without intraoperative perforation. c The patient had epigastric pain 13 hours after ESD. Computed tomography showed free air. d Endoscopy revealed a 5-mm muscle defect in the post-ESD ulcer (yellow head). e The perforation was closed using an OTSC. f After 2 months, the post-ESD ulcer healed, including the perforation.