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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Delayed Perforation after Gastric Endoscopic Submucosal Dissection: Proceed to Prompt Intervention If Acceptable

Seiichiro Abe

Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

Correspondence to: Seiichiro Abe
ORCID https://orcid.org/0000-0002-2736-6921
E-mail seabe@ncc.go.jp

See “Delayed Perforation Occurring after Gastric Endoscopic Submucosal Dissection: Clinical Features and Management Strategy” by Tae-Se Kim, et al. on page 40, Vol. 18, No. 1, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2024;18(1):1-2. https://doi.org/10.5009/gnl230545

Published online January 15, 2024, Published date January 15, 2024

Copyright © Gut and Liver.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for local resection of early gastric cancer with a low risk of nodal metastasis. The clinical indications have been expanded based on the favorable long-term outcomes, although the level of recommendations varies among guidelines.1 ESD allows for high en bloc and R0 resection rates regardless of lesion size and location. A recent multicenter prospective cohort study, the J-WEB EGC study, which included more than 10,000 gastric ESDs, showed that intraoperative perforation and delayed bleeding rates were 4.4% and 2.3%, respectively.2 It is well known that most adverse events could be managed endoscopically without surgical intervention. However, delayed perforation is a rare but serious adverse event that often requires emergency surgery. The J-WEB EGC study reported that the delayed perforation occurred in 0.4% (40/9,616) and emergency surgery for delayed perforation was performed in 0.15% (14/9,616).2 Because delayed perforation can be caused by ischemia due to cautery effect rather than sharp tissue laceration by electrosurgical knife. Although the detailed pathogenesis is unclear, a retrospective study suggested that gastric tube reconstruction after esophagectomy, which can alter the blood supply around the stomach, is the risk factor for delayed perforation.3 It suggests that the size of the necrotic area around the perforation site may be extensive.

In this issue of Gut and Liver, Kim et al.4 conducted a single-center retrospective observational study and reported that delayed perforation occurred in 15 of 11,531 patients (0.13%) undergoing gastric ESD. Of these, nine patients (60%) required emergency surgery. A perforation less than 1 cm in size was observed more frequently in the six patients who underwent successful nonsurgical treatments than in the nine patients who underwent surgery (p<0.001).

To the best of my knowledge, this is the largest cohort study and the data are consistent with previous studies.2,3 The results are appreciated because the authors presented the clinical course after delayed perforation and provided an interesting discussion despite the limitations of a retrospective study. First, all five patients with small perforation sites <1 cm could be managed with conservative treatment or simple clip closure, while the other nine patients with large perforations ≥1 cm required emergency surgery (the size of perforation was not shown in one patient).4 In the present study, the indications for emergency surgery would be determined at the discretion of the referring endoscopists and surgeons. Emergency surgery is generally indicated for delayed perforation. However, it is clinically acceptable to attempt endoscopic intervention in the first instance when inflammation is localized and the consensus is reached after multidisciplinary discussion with surgical colleagues. The results of the present study suggest that simple clip closure is helpful in avoiding emergency surgery for small perforations <1 cm. In addition, some case reports showed that over-the-scope clip closure and tissue shielding with a bioabsorbable polyglycolic acid sheet were effective in avoiding emergency surgery even for a large perforation site.5,6 Further studies are warranted to investigate the efficacy of endoscopic closure of a large perforation site, although the indications should be limited to stable general conditions as well as localized peritonitis.

Moreover, the time to event and the location of the delayed perforation site could also be related to the risk of emergency surgery. Early onset and prompt endoscopic intervention before diet initiation may be beneficial to avoid emergency surgery. Some case reports showed successful conservative management of delayed perforation with endoscopic or spontaneous drainage of perigastric abscess without perforation closure.7,8 It could be explained that the perforation site could be anatomically covered with omentum, which could keep the peritonitis localized. Prophylactic closure of the mucosal defect after ESD is a future innovation to prevent delayed perforation. Currently, some suturing techniques have been developed to achieve complete and sustained closure of a large mucosal defect after gastric ESD, using overstitch device and endoscopic hand suturing. These novel approaches have potential to prevent delayed bleeding as well as perforation, allowing ESD to be in an outpatient setting.9,10 However, they are costly and time consuming, and it is difficult to prove whether the arduous work is worth to prevent the rare adverse event.

Further investigation is warranted to analyze the relationship between the size of the perforation site and the risk of emergency surgery. Clinicians should keep in mind the rare but serious adverse events after gastric ESD and try not to miss the chance of endoscopic approach to achieve nonsurgical treatment.

No potential conflict of interest relevant to this article was reported.

  1. Hirai Y, Abe S, Makiguchi ME, et al. Endoscopic resection of undifferentiated early gastric cancer. J Gastric Cancer 2023;23:146-158.
    Pubmed KoreaMed CrossRef
  2. Suzuki H, Takizawa K, Hirasawa T, et al. Short-term outcomes of multicenter prospective cohort study of gastric endoscopic resection: 'Real-world evidence' in Japan. Dig Endosc 2019;31:30-39.
    Pubmed CrossRef
  3. Suzuki H, Oda I, Sekiguchi M, et al. Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection. World J Gastroenterol 2015;21:12635-12643.
    Pubmed KoreaMed CrossRef
  4. Kim TS, Min BH, Min YW, et al. Delayed perforation occurring after gastric endoscopic submucosal dissection: clinical features and management strategy. Gut Liver 2024;18:40-49.
    Pubmed CrossRef
  5. Ono H, Takizawa K, Kakushima N, Tanaka M, Kawata N. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015;47 Suppl 1 UCTN:E18-9.
    Pubmed CrossRef
  6. Abe S, Yamada M, Oda I. Successful omental patch closure with over-the-scope clip for delayed stomach perforation after endoscopic hemostasis for post-endoscopic submucosal dissection bleeding. Dig Endosc 2019;31 Suppl 1:24-25.
    Pubmed CrossRef
  7. Nagae S, Kimoto Y, Sawada R, et al. Perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection: successful conservative treatment without perforation closure: a case report. J Med Case Rep 2023;17:92.
    Pubmed KoreaMed CrossRef
  8. Takayanagi S, Takita M, Ishii K, Fujita Y, Ohata K. Successful endoscopic ultrasound-guided nasocavitary catheter drainage of abscess caused by delayed perforation after gastric endoscopic submucosal dissection. VideoGIE 2022;7:132-134.
    Pubmed KoreaMed CrossRef
  9. Agnihotri A, Mitsuhashi S, Holmes I, et al. A randomized trial comparing gastric and colorectal endoscopic submucosal dissection defect closure using novel through the scope suturing system with over-the-scope suturing system. Gastrointest Endosc. Epub 2023 Aug 1. https://doi.org/10.1016/j.gie.2023.07.046
    Pubmed CrossRef
  10. Goto O, Oyama T, Ono H, et al. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020;91:1195-1202.
    Pubmed CrossRef

Article

Editorial

Gut and Liver 2024; 18(1): 1-2

Published online January 15, 2024 https://doi.org/10.5009/gnl230545

Copyright © Gut and Liver.

Delayed Perforation after Gastric Endoscopic Submucosal Dissection: Proceed to Prompt Intervention If Acceptable

Seiichiro Abe

Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

Correspondence to:Seiichiro Abe
ORCID https://orcid.org/0000-0002-2736-6921
E-mail seabe@ncc.go.jp

See “Delayed Perforation Occurring after Gastric Endoscopic Submucosal Dissection: Clinical Features and Management Strategy” by Tae-Se Kim, et al. on page 40, Vol. 18, No. 1, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for local resection of early gastric cancer with a low risk of nodal metastasis. The clinical indications have been expanded based on the favorable long-term outcomes, although the level of recommendations varies among guidelines.1 ESD allows for high en bloc and R0 resection rates regardless of lesion size and location. A recent multicenter prospective cohort study, the J-WEB EGC study, which included more than 10,000 gastric ESDs, showed that intraoperative perforation and delayed bleeding rates were 4.4% and 2.3%, respectively.2 It is well known that most adverse events could be managed endoscopically without surgical intervention. However, delayed perforation is a rare but serious adverse event that often requires emergency surgery. The J-WEB EGC study reported that the delayed perforation occurred in 0.4% (40/9,616) and emergency surgery for delayed perforation was performed in 0.15% (14/9,616).2 Because delayed perforation can be caused by ischemia due to cautery effect rather than sharp tissue laceration by electrosurgical knife. Although the detailed pathogenesis is unclear, a retrospective study suggested that gastric tube reconstruction after esophagectomy, which can alter the blood supply around the stomach, is the risk factor for delayed perforation.3 It suggests that the size of the necrotic area around the perforation site may be extensive.

In this issue of Gut and Liver, Kim et al.4 conducted a single-center retrospective observational study and reported that delayed perforation occurred in 15 of 11,531 patients (0.13%) undergoing gastric ESD. Of these, nine patients (60%) required emergency surgery. A perforation less than 1 cm in size was observed more frequently in the six patients who underwent successful nonsurgical treatments than in the nine patients who underwent surgery (p<0.001).

To the best of my knowledge, this is the largest cohort study and the data are consistent with previous studies.2,3 The results are appreciated because the authors presented the clinical course after delayed perforation and provided an interesting discussion despite the limitations of a retrospective study. First, all five patients with small perforation sites <1 cm could be managed with conservative treatment or simple clip closure, while the other nine patients with large perforations ≥1 cm required emergency surgery (the size of perforation was not shown in one patient).4 In the present study, the indications for emergency surgery would be determined at the discretion of the referring endoscopists and surgeons. Emergency surgery is generally indicated for delayed perforation. However, it is clinically acceptable to attempt endoscopic intervention in the first instance when inflammation is localized and the consensus is reached after multidisciplinary discussion with surgical colleagues. The results of the present study suggest that simple clip closure is helpful in avoiding emergency surgery for small perforations <1 cm. In addition, some case reports showed that over-the-scope clip closure and tissue shielding with a bioabsorbable polyglycolic acid sheet were effective in avoiding emergency surgery even for a large perforation site.5,6 Further studies are warranted to investigate the efficacy of endoscopic closure of a large perforation site, although the indications should be limited to stable general conditions as well as localized peritonitis.

Moreover, the time to event and the location of the delayed perforation site could also be related to the risk of emergency surgery. Early onset and prompt endoscopic intervention before diet initiation may be beneficial to avoid emergency surgery. Some case reports showed successful conservative management of delayed perforation with endoscopic or spontaneous drainage of perigastric abscess without perforation closure.7,8 It could be explained that the perforation site could be anatomically covered with omentum, which could keep the peritonitis localized. Prophylactic closure of the mucosal defect after ESD is a future innovation to prevent delayed perforation. Currently, some suturing techniques have been developed to achieve complete and sustained closure of a large mucosal defect after gastric ESD, using overstitch device and endoscopic hand suturing. These novel approaches have potential to prevent delayed bleeding as well as perforation, allowing ESD to be in an outpatient setting.9,10 However, they are costly and time consuming, and it is difficult to prove whether the arduous work is worth to prevent the rare adverse event.

Further investigation is warranted to analyze the relationship between the size of the perforation site and the risk of emergency surgery. Clinicians should keep in mind the rare but serious adverse events after gastric ESD and try not to miss the chance of endoscopic approach to achieve nonsurgical treatment.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Hirai Y, Abe S, Makiguchi ME, et al. Endoscopic resection of undifferentiated early gastric cancer. J Gastric Cancer 2023;23:146-158.
    Pubmed KoreaMed CrossRef
  2. Suzuki H, Takizawa K, Hirasawa T, et al. Short-term outcomes of multicenter prospective cohort study of gastric endoscopic resection: 'Real-world evidence' in Japan. Dig Endosc 2019;31:30-39.
    Pubmed CrossRef
  3. Suzuki H, Oda I, Sekiguchi M, et al. Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection. World J Gastroenterol 2015;21:12635-12643.
    Pubmed KoreaMed CrossRef
  4. Kim TS, Min BH, Min YW, et al. Delayed perforation occurring after gastric endoscopic submucosal dissection: clinical features and management strategy. Gut Liver 2024;18:40-49.
    Pubmed CrossRef
  5. Ono H, Takizawa K, Kakushima N, Tanaka M, Kawata N. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015;47 Suppl 1 UCTN:E18-9.
    Pubmed CrossRef
  6. Abe S, Yamada M, Oda I. Successful omental patch closure with over-the-scope clip for delayed stomach perforation after endoscopic hemostasis for post-endoscopic submucosal dissection bleeding. Dig Endosc 2019;31 Suppl 1:24-25.
    Pubmed CrossRef
  7. Nagae S, Kimoto Y, Sawada R, et al. Perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection: successful conservative treatment without perforation closure: a case report. J Med Case Rep 2023;17:92.
    Pubmed KoreaMed CrossRef
  8. Takayanagi S, Takita M, Ishii K, Fujita Y, Ohata K. Successful endoscopic ultrasound-guided nasocavitary catheter drainage of abscess caused by delayed perforation after gastric endoscopic submucosal dissection. VideoGIE 2022;7:132-134.
    Pubmed KoreaMed CrossRef
  9. Agnihotri A, Mitsuhashi S, Holmes I, et al. A randomized trial comparing gastric and colorectal endoscopic submucosal dissection defect closure using novel through the scope suturing system with over-the-scope suturing system. Gastrointest Endosc. Epub 2023 Aug 1. https://doi.org/10.1016/j.gie.2023.07.046
    Pubmed CrossRef
  10. Goto O, Oyama T, Ono H, et al. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020;91:1195-1202.
    Pubmed CrossRef
Gut and Liver

Vol.18 No.1
January, 2024

pISSN 1976-2283
eISSN 2005-1212

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