Post written by Yohei Minato, MD, from NTT Medical Center Tokyo, Tokyo, Japan.

The video case presents management of a delayed colonic perforation that occurred after endoscopic submucosal dissection (ESD) of a 40-mm superficial neoplastic lesion in the ascending colon. Although the ESD was uneventful, the patient developed abdominal pain the next day, and emergency colonoscopy revealed a 6-mm perforation. The lesion was successfully treated endoscopically with an over-the-scope clip (OTSC), avoiding the need for emergency surgery.

Delayed perforation after colonic ESD is a rare but potentially life-threatening adverse event. This case highlights a nonsurgical, minimally invasive approach using an OTSC for successful closure. Given the limited treatment options for delayed perforation and lack of an established algorithm, sharing this experience may help inform future clinical decision-making.

Endoscopists can learn that emergency colonoscopy, although generally contraindicated in cases of perforation, may be justified if peritonitis is not evident. This case also demonstrates that an OTSC can be an effective tool for managing fragile, necrotic tissue around a delayed perforation site, offering a valuable bridge between standard clip closure and surgery.

Prompt recognition and individualized management of post-ESD adverse events are essential. This case supports the use of an OTSC in challenging scenarios and emphasizes the importance of early intervention before onset of generalized peritonitis.

Post-ESD delayed colonic perforation closed by an OTSC. A, A perforation site was observed in the post-ESD ulcer, distinct from the location where clips were applied during the ESD procedure. B, The clip was removed to facilitate the placement of the OTSC, and the OTSC was set at the perforation site. C, The surrounding tissue of the perforation was grasped with forceps and pulled into the distal attachment. D, The perforation site and the surrounding ulcer base were closed with an OTSC. ESD, Endoscopic submucosal dissection, OTSC, over-the-scope clip.

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