Skip to main content
SpringerLink
Log in

Risk factors for perforations associated with endoscopic submucosal dissection in gastric lesions: emphasis on perforation type

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Endoscopic submucosal dissection (ESD) enables en bloc resection of larger gastric neoplasms. However, the procedure is associated with a high incidence of perforation. Perforations during ESD are divided into macro- and microperforations. Although both types of perforations could cause widespread tissue injury and secondary sepsis, very little is known concerning the risk factors for perforations according to the type of perforation. Thus, this study was performed to evaluate the risk factors for macro-, micro-, and all perforations (both) during ESD.

Methods

823 gastric lesions (gastric adenoma or early gastric cancer) in 729 patients treated by ESD were enrolled, and their records were reviewed retrospectively. Risk factors were evaluated, focusing on age, sex, gastric neoplasm-related factors (12 locations, resected size, gross type of lesions, presence of ulceration, presence of fibrosis, pathologic diagnosis, and depth of invasion), and ESD procedure-related factors (type of knife, immediate bleeding during ESD, en bloc resection, procedure time, and the number of ESD cases experienced by the endoscopist).

Results

Of the 823 gastric lesions, the rates of all perforation, macroperforation, and microperforation were 9.6%, 7.5%, and 2.1%, respectively. Risk factors for all perforations on multivariate analysis were location of tumor in upper portion, presence of fibrosis, and long procedure time (>2 h). Risk factors for macroperforations were the same as all perforations. Risk factors for microperforations on multivariate analysis were old age (≥81 years), depth of invasion (muscularis mucosa), and long procedure time (>2 h).

Conclusions

The risk factors for perforations during ESD could differ according to the type of perforation. Therefore, although macroperforation did not develop during ESD, it would be necessary to consider the possibility of microperforation in case of old age, long procedure time, and (deep) depth of invasion.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Muto M, Miyamoto S, Hosokawa A, Doi T, Ohtsu A, Yoshida S, Endo Y, Hosokawa K, Saito D, Shim CS, Gossner L (2005) Endoscopic mucosal resection in the stomach using the insulated-tip needle-knife. Endoscopy 37:178–182

    Article  PubMed  CAS  Google Scholar 

  2. Gotoda T, Yamamoto H, Soetikno RM (2006) Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 41:929–942

    Article  PubMed  Google Scholar 

  3. Onozato Y, Ishihara H, Iizuka H, Sohara N, Kakizaki S, Okamura S, Mori M (2006) Endoscopic submucosal dissection for early gastric cancers and large flat adenomas. Endoscopy 38:980–986

    Article  PubMed  CAS  Google Scholar 

  4. Imagawa A, Okada H, Kawahara Y, Takenaka R, Kato J, Kawamoto H, Fujiki S, Takata R, Yoshino T, Shiratori Y (2006) Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success. Endoscopy 38:987–990

    Article  PubMed  CAS  Google Scholar 

  5. Kato M, Nishida T, Tsutsui S, Komori M, Michida T, Yamamoto K, Kawai N, Kitamura S, Zushi S, Nishihara A, Nakanishi F, Kinoshita K, Yamada T, Iijima H, Tsujii M, Hayashi N (2011) Endoscopic submucosal dissection as a treatment for gastric noninvasive neoplasia: a multicenter study by Osaka University ESD Study Group. J Gastroenterol 46:325–331

    Article  PubMed  Google Scholar 

  6. Akasaka T, Nishida T, Tsutsui S, Michida T, Yamada T, Ogiyama H, Kitamura S, Ichiba M, Komori M, Nishiyama O, Nakanishi F, Zushi S, Nishihara A, Iijima H, Tsujii M, Hayashi N (2011) Short-term outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasm: multicenter survey by osaka university ESD study group. Dig Endosc 23:73–77

    Article  PubMed  Google Scholar 

  7. Kojima T, Parra-Blanco A, Takahashi H, Fujita R (1998) Outcome of endoscopic mucosal resection for early gastric cancer: review of the Japanese literature. Gastrointest Endosc 48:550–554 discussion 554-555a

    Article  PubMed  CAS  Google Scholar 

  8. Jeon SW, Jung MK, Kim SK, Cho KB, Park KS, Park CK, Kwon JG, Jung JT, Kim EY, Kim TN, Jang BI, Yang CH (2010) Clinical outcomes for perforations during endoscopic submucosal dissection in patients with gastric lesions. Surg Endosc 24:911–916

    Article  PubMed  Google Scholar 

  9. Hanaoka N, Uedo N, Ishihara R, Higashino K, Takeuchi Y, Inoue T, Chatani R, Hanafusa M, Tsujii Y, Kanzaki H, Kawada N, Iishi H, Tatsuta M, Tomita Y, Miyashiro I, Yano M (2010) Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 42:1112–1115

    Article  PubMed  CAS  Google Scholar 

  10. Mannen K, Tsunada S, Hara M, Yamaguchi K, Sakata Y, Fujise T, Noda T, Shimoda R, Sakata H, Ogata S, Iwakiri R, Fujimoto K (2010) Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions. J Gastroenterol 45:30–36

    Article  PubMed  Google Scholar 

  11. Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K, Fujita K, Takahashi H, Yoneda M, Hirokawa S, Goto A, Kirikoshi H, Kobayashi N, Kubota K, Saito S, Nakajima A (2009) Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer. Hepatogastroenterology 56:921–924

    PubMed  Google Scholar 

  12. Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, Kato Y (2000) Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 3:219–225

    Article  PubMed  Google Scholar 

  13. Schlemper RJ, Riddell RH, Kato Y, Borchard F, Cooper HS, Dawsey SM, Dixon MF, Fenoglio-Preiser CM, Flejou JF, Geboes K, Hattori T, Hirota T, Itabashi M, Iwafuchi M, Iwashita A, Kim YI, Kirchner T, Klimpfinger M, Koike M, Lauwers GY, Lewin KJ, Oberhuber G, Offner F, Price AB, Rubio CA, Shimizu M, Shimoda T, Sipponen P, Solcia E, Stolte M, Watanabe H, Yamabe H (2000) The Vienna classification of gastrointestinal epithelial neoplasia. Gut 47:251–255

    Article  PubMed  CAS  Google Scholar 

  14. Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, Yoshihara M, Chayama K (2006) Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 64:877–883

    Article  PubMed  Google Scholar 

  15. Onogi F, Araki H, Ibuka T, Manabe Y, Yamazaki K, Nishiwaki S, Moriwaki H (2010) “Transmural air leak”: a computed tomographic finding following endoscopic submucosal dissection of gastric tumors. Endoscopy 42:441–447

    Article  PubMed  CAS  Google Scholar 

  16. Chung IK, Lee JH, Lee SH, Kim SJ, Cho JY, Cho WY, Hwangbo Y, Keum BR, Park JJ, Chun HJ, Kim HJ, Kim JJ, Ji SR, Seol SY (2009) Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc 69:1228–1235

    Article  PubMed  Google Scholar 

  17. Minami S, Gotoda T, Ono H, Oda I, Hamanaka H (2006) Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 63:596–601

    Article  PubMed  Google Scholar 

  18. Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, Yamamichi N, Tateishi A, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2007) Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol 5:678–683 quiz 645

    Article  PubMed  Google Scholar 

  19. Nishiyama H, Isomoto H, Yamaguchi N, Fukuda E, Ikeda K, Ohnita K, Mizuta Y, Nakamura T, Nakao K, Kohno S, Shikuwa S (2010) Endoscopic submucosal dissection for colorectal epithelial neoplasms. Dis Colon Rectum 53:161–168

    Article  PubMed  Google Scholar 

  20. Isomoto H, Nishiyama H, Yamaguchi N, Fukuda E, Ishii H, Ikeda K, Ohnita K, Nakao K, Kohno S, Shikuwa S (2009) Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 41:679–683

    Article  PubMed  CAS  Google Scholar 

  21. Lee IL, Wu CS, Tung SY, Lin PY, Shen CH, Wei KL, Chang TS (2008) Endoscopic submucosal dissection for early gastric cancers: experience from a new endoscopic center in Taiwan. J Clin Gastroenterol 42:42–47

    Article  PubMed  Google Scholar 

  22. Kakushima N, Fujishiro M, Kodashima S, Muraki Y, Tateishi A, Omata M (2006) A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms. Endoscopy 38:991–995

    Article  PubMed  CAS  Google Scholar 

  23. Kim ES, Cho KB, Park KS, Lee KI, Jang BK, Chung WJ, Hwang JS (2011) Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy, doi:10.1055/s-0030-1256339, Mar 31, 2011

  24. Saul SH, Dekker A, Watson CG (1981) Acute gastric dilatation with infarction and perforation. Report of fatal outcome in patient with anorexia nervosa. Gut 22:978–983

    Article  PubMed  CAS  Google Scholar 

  25. Turan M, Sen M, Canbay E, Karadayi K, Yildiz E (2003) Gastric necrosis and perforation caused by acute gastric dilatation: report of a case. Surg Today 33:302–304

    Article  PubMed  Google Scholar 

  26. Kawaguchi H, Haruma K, Komoto K, Yoshihara M, Sumii K, Kajiyama G (1996) Helicobacter pylori infection is the major risk factor for atrophic gastritis. Am J Gastroenterol 91:959–962

    PubMed  CAS  Google Scholar 

  27. Isomoto H, Ohnita K, Yamaguchi N, Fukuda E, Ikeda K, Nishiyama H, Akiyama M, Ozawa E, Nakao K, Kohno S, Shikuwa S (2010) Clinical outcomes of endoscopic submucosal dissection in elderly patients with early gastric cancer. Eur J Gastroenterol Hepatol 22:311–317

    Article  PubMed  Google Scholar 

  28. Kakushima N, Fujishiro M, Kodashima S, Muraki Y, Tateishi A, Yahagi N, Omata M (2007) Technical feasibility of endoscopic submucosal dissection for gastric neoplasms in the elderly Japanese population. J Gastroenterol Hepatol 22:311–314

    Article  PubMed  Google Scholar 

  29. Lee H, Yun WK, Min BH, Lee JH, Rhee PL, Kim KM, Rhee JC, Kim JJ (2011) A feasibility study on the expanded indication for endoscopic submucosal dissection of early gastric cancer. Surg Endosc 25:1985–1993

    Article  PubMed  Google Scholar 

Download references

Disclosures

Authors Jun-Hwan Yoo, Sung-Jae Shin, Kee-Myung Lee, Jae-Myoung Choi, Jeong-Ook Wi, Dong-Hoon Kim, Sun-Gyo Lim, Jae-Chul Hwang, Jae-Youn Cheong, Byung-Moo Yoo, Kwang-Jae Lee, Jin-Hong Kim, and Sung-Won Cho have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, San5, Wonchondong, Yoengtongku, Keongkido, Suwon, 443-721, South Korea

    Jun Hwan Yoo, Sung Jae Shin, Kee Myung Lee, Jae Myoung Choi, Jeong Ook Wi, Dong Hoon Kim, Sun Gyo Lim, Jae Chul Hwang, Jae Youn Cheong, Byung Moo Yoo, Kwang Jae Lee, Jin Hong Kim & Sung Won Cho

Authors
  1. Jun Hwan Yoo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sung Jae Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kee Myung Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jae Myoung Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jeong Ook Wi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Dong Hoon Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sun Gyo Lim
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jae Chul Hwang
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jae Youn Cheong
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Byung Moo Yoo
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Kwang Jae Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Jin Hong Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Sung Won Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sung Jae Shin.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Yoo, J.H., Shin, S.J., Lee, K.M. et al. Risk factors for perforations associated with endoscopic submucosal dissection in gastric lesions: emphasis on perforation type. Surg Endosc 26, 2456–2464 (2012). https://doi.org/10.1007/s00464-012-2211-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-012-2211-x

Keywords

Search

Navigation