Clin Endosc.  2015 Nov;48(6):570-575. 10.5946/ce.2015.48.6.570.

Unexpected Delayed Colon Perforation after the Endoscopic Submucosal Dissection with Snaring of a Laterally Spreading Tumor

• Ko YB
• Lee JM
• Kim WS
• Kwak MS
• Lee JW
• Shin DY
• Yang DH
• Byeon JS

• KMID: 2380419
• DOI: http://doi.org/10.5946/ce.2015.48.6.570

Abstract

Colonic perforation may occur as a complication of diagnostic and therapeutic colonoscopy. The risk factors for perforation after colorectal endoscopic submucosal dissection (ESD) include an inexperienced endoscopist, a large tumor size, and submucosal fibrosis. The mechanisms of perforation include unintended endoscopic resection/dissection and severe thermal injury. Here, we report a case of colon perforation that occurred after ESD with snaring of a laterally spreading tumor. The perforation was completely unexpected because there were no colorectal ESD-associated risk factors for perforation, deep dissection, or severe coagulation injury in our patient.

Keyword

Delayed perforation; Risk factor; Mechanism; Endoscopic submucosal dissection

MeSH Terms

Colon*
Colonoscopy
Fibrosis
Humans
Risk Factors
SNARE Proteins*
SNARE Proteins

Figure

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  Fig. 1. (A) Nongranular laterally spreading tumor in the transverse colon. (B) Submucosal dissection was performed. (C) After partial endoscopic submucosal dissection (ESD), the lesion was removed en bloc by means of snaring. (D) En bloc resection was completed, and the post-ESD ulcer base was clean without bleeding, severe coagulation injury, or endoscopically evident perforation.

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  Fig. 2. (A, B) Pneumoperitoneum on simple abdominal imaging and abdominopelvic computed tomography (arrows). (C, D) Transverse colon wall thickening and irregularity (arrowheads) with pericolic free air.

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  Fig. 3. Endoscopic resection specimen. (A) The specimen has mucosal and submucosal layers without the muscularis layer of the colonic wall (H&E stain, ×40). (B) Submucosal layer showing submucosal vessels (arrow) without severe coagulation damage due to thermal injury (H&E stain, ×100).

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  Fig. 4. Surgical resection specimen. (A) Large hematoma (long arrow) in the proper muscle layer. The endoscopic resection site (short arrows) and perforation site (arrowheads) are also shown (H&E stain, ×12.5). (B) Perforation site in the specimen (H&E stain, ×40). (C) Necrosis in the colonic wall is evident at the perforation site (arrow) (H&E stain, ×100). (D) Neutrophil infiltration is evident at the perforation site (H&E stain, ×200).

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