Clinical outcomes for perforations during endoscopic submucosal dissection in patients with gastric lesions

Abstract

Background The endoscopic submucosal dissection (ESD) technique has been gaining popularity, with continued advances in this treatment approach. However, ESD still is associated with potential complications such as severe bleeding and perforation. Methods This study was performed to compare the clinical outcomes for macro- and microperforations with ESD procedures and to determine the short-term prognosis after ESD. A macroperforation was defined as a gross perforation that occurred during an ESD procedure, and a microperforation was defined by free air observed on simple radiography after the procedure. Immediate closure of macroperforations was performed using endoclips. From July 2003 through May 2008, 1,711 patients underwent ESD for gastric lesions such as dysplasia, early cancer, and subepithelial lesions. Results Among 39 perforation cases (2.3%), macroperforations occurred for 26 patients (67%) and microperforations for 13 patients (33%). All the patients except one who underwent emergency surgery because of severe bleeding and perforation during ESD were managed successfully by intravenous antibiotics and no oral intake. The clinical prognosis and endoscopic characteristics of the patients with macroperforations did not differ from those of the patients with microperforations. Conclusions Perforations associated with ESD could be managed safely and successfully by nonsurgical methods. The clinical prognoses for macro- and microperforations were favorable and comparable. Keywords Gastroscopic surgical procedure Pneumoperitoneum Stomach neoplasia Endoscopic submucosal dissection (ESD) is widely accepted in Korea and Japan as an alternative to surgery for the complete resection of gastric lesions [1]. The ESD procedure is regarded as more effective than other endoscopic methods for the treatment of gastric lesions because it provides en bloc specimens for pathologic evaluation. Compared with open surgery, ESD is relatively noninvasive. This has made it a desirable technique. However, significant complications have been associated with ESD [2–4]. Bleeding is a more common complication of ESD than of endoscopic mucosal resection (EMR). The frequency of bleeding, reported to be 7% to 38%, has been associated with the site of the lesions [5–7]. In addition, the perforation frequency is reported to be higher with the ESD (4%) than with EMR (0.5%) [8, 9]. These complications have limited the use of ESD, although it provides en bloc complete resection samples. Several recent studies have shown that the recovery rate for patients who have iatrogenic perforations associated with ESD treated conservatively was the same as for patients without such complications [2, 8, 10]. Perforations that occur in relation to ESD are divided into macro- and microperforations. Macroperforations usually are noted during the procedure and can be treated successfully with endoclips. However, microperforations usually are diagnosed by free air on plain x-rays after the procedure. Currently, very little information exists on the outcome for patients with these two types of perforations. Therefore, in this study, we investigated the frequency and clinical outcomes for macro- and microperforations in a large series of patients undergoing ESDs.