Clin Endosc.  2023 Jul;56(4):423-432. 10.5946/ce.2023.104.

Management of complications related to colorectal endoscopic submucosal dissection

• Gweon TG
• Yang DH

• KMID: 2544563
• DOI: http://doi.org/10.5946/ce.2023.104

Abstract

Compared to endoscopic mucosal resection (EMR), colonoscopic endoscopic submucosal dissection (C-ESD) has the advantages of higher en bloc resection rates and lower recurrence rates of colorectal neoplasms. Therefore, C-ESD is considered an effective treatment method for laterally spread tumors and early colorectal cancer. However, C-ESD is technically more difficult and requires a longer procedure time than EMR. In addition to therapeutic efficacy and procedural difficulty, safety concerns should always be considered when performing C-ESD in clinical practice. Bleeding and perforation are the main adverse events associated with C-ESD and can occur during C-ESD or after the completion of the procedure. Most bleeding associated with C-ESD can be managed endoscopically, even if it occurs during or after the procedure. More recently, most perforations identified during C-ESD can also be managed endoscopically, unless the mural defect is too large to be sutured with endoscopic devices or the patient is hemodynamically unstable. Delayed perforations are quite rare, but they require surgical treatment more frequently than endoscopically identified intraprocedural perforations or radiologically identified immediate postprocedural perforations. Post-ESD coagulation syndrome is a relatively underestimated adverse event, which can mimic localized peritonitis from perforation. Here, we classify and characterize the complications associated with C-ESD and recommend management options for them.

Keyword

Colorectal neoplasms; Endoscopic submucosal dissection; Hemorrhage; Intraoperative complications; Intestinal perforation

Figure

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  Fig. 1. Coagulation of large vessels in the submucosal layer. (A) During submucosal dissection, large vessels were exposed at the submucosal layer. (B) Vessels were coagulated with a coagrasper. (C) Coagulated vessels.

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  Fig. 2. Perforation closure simply using conventional hemoclips. (A) Overt intraprocedural perforation was determined when the submucosal dissection was almost finished. (B) After completion of endoscopic submucosal dissection, the defect of the proper muscle layer was directly closed using a clip. (C) To ensure complete endoscopic closure, mucosa and submucosal layers adjacent to the perforated site were tightly closed using additional clips.

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  Fig. 3. Perforation closure using the ziplock method. (A) Iatrogenic colon perforation during colonoscope insertion. (B) The first clip was placed at the lateral side of colon perforation. (C) Perforation was completely closed using additional clips. Adapted from closure of iatrogenic colon perforation during colonoscope insertion, courtesy of Prof. Yunho Jung, Soonchunhyang University College of Medicine.

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  Fig. 4. Identification of perforation concealed with the omentum. Extraluminal fat tissue was observed under a tiny proper muscle layer defect. Arrows indicate the concealed perforation site.

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  Fig. 5. Over-the-scope clip (Ovesco Endoscopy AG).

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  Fig. 6. Endoloop and clip fixation for the treatment of perforation. (A) Large perforation. Arrows indicate the perforation site. (B) The first clip was fixed with an endoloop at normal colonic mucosa. (C) The second and third clips were placed to different side colon mucosa around the dissected ulcer. (D) The endoloop was tightened to close perforation.

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  Fig. 7. Endoscopic closure using the traction method. (A) A perforation of 6 mm in size is shown. Arrow indicates the perforation site. (B) One clip was fixed with a rubber band at the colonic mucosa. (C) Ulcer was partially approximated using the traction method (D) Additional clips were placed with ease after approximation. (E) Complete closure of the ulcer.

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  Fig. 8. Recommended area for needle decompression. Area in the dotted red line indicates suggested area.

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  Fig. 9. Post-endoscopic submucosal dissection coagulation syndrome. (A) After completion of submucosal dissection, neither deep proper muscle injury, nor overt perforation were suspected. (B) Clips were placed at the site of proper muscle injury. (C) Owing to abdominal pain and fever after the procedure, computed tomography was performed, revealing edematous wall thickening at the procedure site. Courtesy of Prof. Yunho Jung, Soonchunhyang University College of Medicine.

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