Post written by Leonardo Zorron Cheng Tao Pu, MD, MSc, FBCS, FASGE, from the Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, Australia.

In our video a 61-year-old woman was submitted to piecemeal EMR for a large lateral spreading tumor at the recto-sigmoid junction. After the second piece was resected, we noted a suspicious area of possible perforation. Although we could identify the white cautery ring at the resection area, it called our attention that it did not display one of the typical features of a perforation: a black hole. We then reminded ourselves that we were working in an extra-peritoneal segment and this typical feature would not be found. We proceed to inspect the resected specimen and, sure enough, the target sign was present. The perforation was then carefully closed with clips to avoid the surrounding neoplastic tissue, and the EMR was completed.

Figure 1. A, Laterally spreading tumor at the rectosigmoid junction. B, Suspected site of perforation, with a whitish circular ring and bluish base. C, Closure of perforation with 6 hemoclips. D, Resection of remainder of the polyp. E, Resected specimen showing the target sign. F, Histology slide showing the muscularis propria, confirming the perforation. G, Abdominal CT view showing no evidence of perforation. Yellow arrow indicates endoscopic clips.

The blueish color at the area of the perforation as opposed to the classical black hole can give a false sense of security to the endoscopist. Usually the blue color means that we are still in the submucosa layer and it is safe to proceed, but this might be different in an extra-peritoneal segment. It is important to have an increased awareness of the different features of a perforation to recognize it in an extra-peritoneal area, specifically while doing endoscopic resection. Thus, with the suspicion of a perforation, other signs such as the target sign should be actively sought.

This case highlights an atypical feature of an extra-peritoneal perforation. Endoscopists should not rely only on the color of the background while performing endoscopic resection to diagnose a perforation (ie, black vs blue). In addition, we show that even if a perforation is detected, it is feasible to complete the procedure if the closure is made carefully, avoiding grasping neoplastic tissue with the clips.

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