Safety and feasibility of intensive endoscopic interventions for delayed perforation after colorectal endoscopic submucosal dissection (with video)

Abstract

Background and aims: Colorectal endoscopic submucosal dissection (ESD) is widely performed for large superficial colorectal tumors; however, it can lead to adverse events such as delayed perforation, which may require emergency surgery. Our goal was to elucidate the clinical course of delayed perforation and the safety and feasibility of intensive endoscopic interventions.

Methods: Patients diagnosed with delayed perforation after colorectal ESD between February 2011 and April 2023 were retrospectively analyzed. Delayed perforation was defined as follows: no perforation during ESD; abdominal pain and fever after ESD; and extraluminal gas identified during CT imaging.

Results: ESD was performed for 1763 patients with 1845 lesions (right-sided colon, 1018; left-sided colon, 827). Thirty-three delayed perforations (27 between 2011 and 2020; 6 between 2021 and 2023) occurred. Muscle injury occurred during ESD in 4 patients. The ESD ulcer was closed in 6 patients. CT imaging was performed when abdominal pain with fever (n = 17), abdominal pain (n = 13), fever (n = 2), and fatigue (n = 1) were observed. The median period between ESD and CT imaging was 22 hours (IQR, 8-41.25 hours). Seven patients required emergency surgery between 2011 and 2020; of these patients, 5 underwent surgery within 6 hours after CT imaging and 2 required surgery after conservative treatment. Endoscopy was performed for 5 of 6 patients between 2021 and 2023. Endoscopic intervention and successful conservative treatment were performed after identification of the perforation.

Conclusions: Intensive endoscopic interventions for delayed perforation after ESD may prevent emergency surgery.