Colon - Endoscopic Closure of Colonic Perforations after EMR or ESD for Early Colon Cancer
Comments: Introduction
Endoscopic submucosal dissection (ESD) for colorectal cancer is not widely accepted because of its technical difficulty and the greater risk of perforation. The en-bloc resection rate using ESD has been reported to be considerably higher compared to conventional endoscopic mucosal resection (EMR), but the perforation rate for ESD also has been higher than conventional EMR. There have been reports that perforation during ESD usually are smaller compared to EMR and, therefore, are easier to close endoscopically.
Case Reports
Two cases are reported here of early colon cancer in which patients sustained iatrogenic perforation of the cecum during conventional EMR and the recto-sigmoid colon during ESD, respectively, requiring abdominal decompression with an 18G Medicut needle.
Case 1
A 35mm pedunculated villous tumor was located in the cecum. Submucosal (sm) invasion could not be ruled out completely because of the large tumor size although magnifying endoscopy revealed a non-invasive pattern. The non-lifting sign was negative so we used conventional EMR because of the lesion's polypoid morphology.
Video Presentation 1
Glycerol was injected into the submucosal layer and sufficient sm lifting was achieved, but a conventional snare (25mm Snare Master, Olympus, Tokyo,Japan) was inadequate for such a large lesion. A prototype 30mm hard snare was then used in order to perform an en-bloc resection. The endoscopist loosened the snare slightly to avoid involving the muscle layer and the patient complained of no pain during snaring of the lesion. After resection, we identified a large perforation approximately, but some intestinal fluid flowed into the abdominal cavity because of the lumen collapsing.
Abdominal Decompression
There was no need for abdominal decompression because the patient did not complain of abdominal pain or discomfort and complete closure of the colonic perforation was performed using endoclips. The EMR was subsequently completed and an en-bloc resection was achieved I 30 minutes. Steromicroscopic examination of the resected specimen showed a definite layer of muscle at the margin cut.
CT Examination
Computed tomography (CT) one day after the EMR showed fluid collection close to the perforation site and an abscess was suspected, but abdominal pain and rebound tenderness were slight. One week later, fluid collection had completely disappeared.
Clinical Course
This patient was treated by withholding oral intake and administering antibiotics for five days and his post-treatment course was uneventful. He experienced slight tenderness and rebound pain for three days, his CRP dropped from 6.7mg/ dl to 0.8mg after five days and the amount of free air in his abdomen decreased considerably by the end of the first week. The patient began to eat five days following the successful clipping procedure and was discharged after one week. Histological diagnosis was a well-differentiated adenocarcinoma with vertical and lateral cut margins both historically negative, but depth of invasion was sm deep (sm2: 1200mm) so the result was a non-curative resection requiring follow-up surgery.
Case 2
A 25mm O-IIa+IIc (LST-NG) lesion was located in the recto-sigmoid colon, but sm invasion was ruled out because magnifying endoscopy revealed a non —invasive pattern. ESD was performed because of the lesion's flat morphology in accordance with ESD criteria at the National Cancer Center Hospital I Tokyo. Tattooing was performed for this lesion in the patient's previous hospital.
Video Presentation
A routine ESD was performed, but the sm layer was difficult to identify because of the previous tattooing. A small pin-hole perforation occurred during the procedure due to poor visualization of the sm layer. We managed pneumoperitoneum by means of abdominal decompression using an 18G Medicut needle to decrease patient discomfort and prevent colonic lumen collapse. Endoscopic clipping was immediately performed after the decompression procedure and ESD was subsequently completed with an enbloc resection achieved in one hour. Histological diagnosis was a well-differentiated adenocarcinoma and depth of invasion was sm superficial (sm1: 750mm). Both the vertical and lateral cut margins were negative with no lymphatic or vessel invasion historically so a curative resection was achieved in this case.
Clinical Course
This slide shows the clinical course of this patient who was treated with intravenous feeding for five days following the perforation. Combined antibiotics of CMZ and Daracin were administered intravenously and the patient wad discharged 10 days later because of the complete improvement of his symptoms.
Comparison of Clinical Outcome — EMR vs ESD
This table indicates the comparative results between EMR and ESD. As shown, the mean tumor size is large and the mean operation time is longer in ESD group. As for complications, perforation occur more frequently in the ESD group (NS), but delayed bleeding occurs more frequently in the EMR group (NS).
Discussion- Clinical usefulness of CO2 Insufflation
We have been using carbon dioxide (CO2) insufflation for colonic ESD;s recently I order to decrease patient discomfort. Although we have experienced small colonic perforation in some cases, there have been no abdominal distension or free air observed on abdominal X-rays probably due to rapid absorptions of CO2 compared to conventional air. As a result, we have been able to close colonic perforations without needing to either hurry or perform abdominal decompression. We believe that CO2 insufflations is advisable for endoscopic therapeutic procedures such as ESD and EMR there fore, in order to decrease the risk of pneumoperitoneum caused by colonic perforations.
Conclusion
In conclusion, conservative clinical management may be possible in patients who have undergone successful colonic perforation closures using endoscpic clipping. In performing immediate endoscopic closure, abdominal decompression has been useful in reducing patient discomfort and preventing colonic lumen collapse in the past, but CO2 insufflations is now being used effectively for the prevention of pneumoperitoneum.
| Contributed by: |
Yutaka Saito, MD, PhD Physician National Cancer Center Hospital, Japan |
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Citation: Saito, Y. (May 19 2008). Colon - Endoscopic Closure of Colonic Perforations after EMR or ESD for Early Colon Cancer. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=762 Times viewed since Feb 2006: 5160 |
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