Colorectal endoscopic submucosal dissection (ESD) is becoming the standard of care
for colorectal tumors; however, troubleshooting for complications remains a challenge,
particularly when dealing with large intraoperative perforations [1]
[2]
[3]. Here, we present a case where such a large perforation was successfully treated
with polyglycolic acid (PGA) sheets and a purse-string suture method using a detachable
snare.
A 76-year-old woman was referred to our institution for treatment of a large flat-elevated
rectal tumor. Colonoscopy revealed that the tumor involved two-thirds of the circumferential
surface, and covered the area above and below the peritoneal reflection, and extended
to the anal margin ([Fig. 1]). The entire lesion was soft, and magnifying chromoendoscopy using crystal violet
staining identified type IV and V irregular low-pit patterns; thus, we diagnosed the
lesion as adenoma or intramucosal adenocarcinoma. Computed tomography (CT) showed
no lymph node or distant metastasis, and ESD was performed.
Fig. 1 Endoscopic findings of two-thirds of the circumferential flat-elevated type of rectal
tumor. The tumor resembled a collection of small lesions, and the boundaries of some
lesions were unclear.
The lesion was difficult to dissect because of the high degree of fibrosis. However,
when approximately 90 % of the dissection was completed, a large, approximately 40 mm,
perforation was identified ([Fig. 2]). The lesion was excised as quickly as possible, and the purse-string suture method
was used to close the perforation ([Fig. 3]). PGA sheets were used to fill the gap, and fibrin glue was sprayed ([Video 1]). CT, obtained immediately after the procedure, showed fluid retention, increased
lipid density around the rectum, and retroperitoneal emphysema extending around the
right kidney. The patient was managed conservatively, She resumed eating 7 days post
ESD and was discharged on Day 11.
Fig. 2 Giant perforation of the lower rectum, measuring 40 mm in size, located below the
peritoneal reflection (areas marked with blue arrows). The serosa and retroperitoneal
cavity were visible at the perforation site.
Fig. 3 Endoscopy images. a The detachable snare was spread around the perforation and fixed to the muscle layer
or mucosa with clips. b By tightening the fixed detachable snare, the purse-string suture method was used
to close the perforation. Polyglycolic acid sheets filled the gap, and fibrin glue
was sprayed.
Video 1 Management of intraoperative giant perforation of colorectal endoscopic submucosal
dissection.
Although colonoscopy performed 8 weeks after discharge showed mild postoperative stenosis,
partial obstruction was not observed, and no local recurrence occurred ([Fig. 4]). The resected specimen was 80 × 66 mm in size and contained a 78 × 64 mm tumor.
Histopathological analysis revealed high-grade tubular adenoma.
Fig. 4 Colonoscopy 8 weeks after endoscopic submucosal dissection showed mild stenosis but
no passage obstruction.
Endoscopy_UCTN_Code_CPL_1AJ_2AD
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