Risk Factors, Clinical Course, and Management of Delayed Perforation After Colorectal Endoscopic Submucosal Dissection: A Large-Scale Multicenter Study

Abstract

Introduction: Delayed perforation (DP) remains a significant complication of colorectal endoscopic submucosal dissection (ESD). This study analyzed the risk factors, clinical course, and management for DP following colorectal ESD.

Methods: We retrospectively reviewed 4,632 consecutive colorectal ESD cases from 13 institutions between January 2006 and May 2024. DP cases were identified, and the incidence rate, along with patient/lesion characteristics (as tumor size, location, and severe fibrosis) were assessed. The clinical course, including onset timing, initial treatments, need for surgery, and risk factors were examined.

Results: DP occurred in 18 cases, with an incidence rate of 0.39% [95% confidence interval (CI): 0.24-0.62]. The mean tumor size was 49.7 ± 35.7 mm. The rates of right-sided colon lesions and severe fibrosis were observed in 77.8 and 61.2%, respectively. DP occurred on post-procedure day 1 in 55.8% of cases, day 2 in 22.2%, and on day 3 or later in 22.2%. Initial DP management included conservative treatment in five cases (27.8%), endoscopic closure in six (33.3%), and surgery in seven cases (38.9%). Among the six cases managed endoscopically, five (83.3%) were successfully managed without surgery. Finally, surgery was required in 11 cases (61.1%). Multivariate analysis (odds ratio [95%CI]) identified severe fibrosis (4.61 [1.50-14.20], p = 0.007), and long procedure time (1.01 [1.00-1.02], p = 0.042), as significant risk factors for DP, while complete closure was inversely correlated with DP risk (0.12 [0.01-0.96], p = 0.046).

Conclusions: This study identified DP incidence and risk factors after colorectal ESD, with some cases requiring surgery. Endoscopic treatment may prevent surgery.

Keywords: Clipping; Colorectum; Delayed perforation; Endoscopic closure; Endoscopic submucosal dissection.

Fig. 1

Study flow

Fig. 2

The clinical course of cases with DP in colorectal ESD

Fig. 3

A case with DP treated by endoscopic closure. a A 76-year-old man. A protruding lesion of 40 mm in size on the ascending colon. ESD was performed and severe fibrosis was dissected. b The tumor could be resected en-bloc (Total procedure time: 120 min). Endoscopic clipping was performed for the severe fibrosis area after ESD. c On postoperative day 1, the patient developed a fever of 38.1 °C without abdominal pain and laboratory tests revealed a WBC of 18,500/μl and a CRP of 2.37 mg/dL. On postoperative day 3, the patient complained minor abdominal pain with mild rebound tenderness and urgent CT showed DP with localized free air and fluid around the ESD site. d Urgent colonoscopy detected an ESD ulcer. A partial deep wound at the oral margin of the ulcer (white arrow) was confirmed perforation by contrast medium through the catheter. e The leak of contrast medium (iopamidol) was found. f The wound and the ulcer were closed with two kinds of clips such as Sure Clips (Micro-Tech, Nanjin, China) and Resolution clip 360 (Boston Scientific Co., MA, USA) due to closure ability and cost. After the endoscopic closure, the leakage was successfully resolved according to the re-examination of CT and the patient's clinical condition improved. He was discharged seven days post-ESD