Delayed perforation 10 days after endoscopic hemostasis using hemostatic forceps for a bleeding Dieulafoy lesion
22. März 2013 (online)
To our knowledge, there have been no reports in the English literature of cases of delayed perforation occurring more than 2 days after hemostasis for gastrointestinal bleeding, including bleeding related to endoscopic submucosal dissection. Additionally, according to previous reports  , in patients with delayed perforation, surgery was often required to improve their clinical course. We report a rare case of successful conservative treatment for delayed perforation occurring 10 days after endoscopic hemostasis using hemostatic forceps for a bleeding Dieulafoy lesion.
An 83-year-old man was admitted to our hospital for the treatment of early gastric cancer. The patient underwent pylorus-preserving gastrectomy and lymph node dissection. On postoperative day 26, he had massive hematemesis. Emergent endoscopy showed a bleeding Dieulafoy lesion at the greater curvature of the gastric remnant ([Fig. 1 a]). The bleeding point was grasped and coagulated with hemostatic forceps (Coagrasper, FD-410LR; Olympus, Tokyo, Japan), using the soft coagulation mode at 80 W ([Fig. 1 b]). Follow-up endoscopic examinations showed no evidence of delayed bleeding at the hemostatic site on days 3 and 7 after the hemostasis procedure ([Fig. 2]). However, on day 10 after hemostasis, the patient complained of severe upper abdominal pain. Free air and ascites were seen in the peritoneal cavity on emergent computed tomography and endoscopic examination revealed a perforation of 3 mm in diameter in the hemostatic ulcer ([Fig. 3 a]). The perforation was closed endoscopically with nine endoclips (HX-600-090L; Olympus) ([Fig. 3 b]). The general condition of the patient as well as the laboratory data and radiographic findings gradually improved, and 40 days after the perforation he was discharged.
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