Post written by Satoki Shichijo, MD, PhD, from Osaka International Cancer Institute, Osaka, Japan.

Endoscopic submucosal dissection (ESD) was performed for 1763 patients with 1845 lesions (right-sided colon, 1018; left-sided colon, 827) between February 2011 and April 2023. Thirty-two delayed perforations (26 between 2011 and 2020; 6 between 2021 and 2023) occurred. Muscle injury occurred during ESD in 4 patients. The ESD ulcer was closed in 6 patients. CT was performed when abdominal pain with fever (n = 17), abdominal pain (n = 13), fever (n = 2), and fatigue (n = 1) were observed. The median period between ESD and CT was 22 hours (IQR, 8-41.25 hours).

Seven patients required emergency surgery between 2011 and 2020; of these patients, 5 underwent surgery within 6 hours after CT and 2 required surgery after conservative treatment. Endoscopy was performed in 5 of 6 patients between 2021 and 2023. Endoscopic intervention and successful conservative treatment were performed after identification of the perforation.

Colorectal ESD is widely performed for large superficial colorectal tumors; however, it can lead to adverse events such as delayed perforation, which may require emergency surgery. Thus, we aimed to elucidate the clinical course of delayed perforation and the safety and feasibility of intensive endoscopic interventions.

Emergency surgery was performed for a higher proportion of patients with perforations in the cecum and sigmoid colon. Intensive endoscopic interventions may prevent emergency surgery.

An ongoing prospective study with the aim of determining the safety and efficacy of intensive endoscopic interventions for delayed perforation after colorectal ESD is underway (UMIN000049968).

Endoscopic interventions for delayed perforations. A, A 2-mm perforation is identified in the cecum slightly distant from where clipping was performed for a muscle injury. B, A polyglycolic acid sheet is placed and fixed with fibrin glue. C, A 3-mm hole in the ulcer in the descending colon caused by endoscopic submucosal dissection. D, An over-the-scope clip is deployed.

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