Abstract
A female in her 70s underwent esophagogastroduodenoscopy (EGD) for screening, and a 0-IIa lesion measuring approximately 15 mm was detected in the descending portion of the duodenum. Due to the malignant potency of the lesion, endoscopic submucosal dissection (ESD) was performed. Microperforation occurred during ESD. The lesion was removed en bloc and the post-ESD ulcer bed was closed with clips. The next day, the patient had abdominal pain and computed tomography (CT) revealed a small amount of free air in the retroperitoneal space. Since there were no findings to suggest panperitonitis, conservative medical management including fasting and antibiotics was continued. Abdominal pain subsequently improved. However, EGD on the 8th day after ESD for follow-up showed shedding of the post-ESD ulcer that penetrated the retroperitoneal space. A surgical approach was not indicated because a few days may have already passed since postoperative perforation occurred and the spread of inflammation to the retroperitoneum was suspected. In an attempt to promote closure of the perforated cavity, we patched polyglycolic acid sheets and fibrin glue to the cavity wall on days 17, 18, and 20 after ESD. The formation of granulation tissue was detected in the cavity one week later. CT showed an abscess in the right retroperitoneum, for which CT-guided abscess puncture was performed. Thereafter, the cavity gradually decreased. After the initiation of oral intake on postoperative day (POD) 63, the general condition of the patient was stable and she was discharged on POD 87. Polyglycolic acid sheets with fibrin glue and CT-guided abscess puncture were useful for closing the large cavity that developed after duodenal postoperative perforation.
Similar content being viewed by others
References
Hoteya S, Yahagi N, Iizuka T, et al. Endoscopic submucosal dissection for nonampullary large superficial adenocarcinoma/adenoma of the duodenum: feasibility and long-term outcomes. Endosc Int Open. 2013;1:2–7.
Miura Y, Shinozaki S, Hayashi Y, et al. Duodenal endoscopic submucosal dissection is feasible using the pocket-creation method. Endoscopy. 2017;49:8–14.
Hoteya S, Furuhata T, Takahito T, et al. Endoscopic submucosal dissection and endoscopic mucosal resection for non-ampullary superficial duodenal tumor. Digestion. 2017;95:36–42.
Fujihara S, Mori H, Kobara H, et al. Management of a large mucosal defect after duodenal endoscopic resection. World J Gastroenterol. 2016;22:6595–609.
Maniwa T, Kaneda H, Saito Y. Management of a complicated pulmonary fistula caused by lung cancer using a fibrin glue-soaked polyglycolic acid sheet covered with an intercostal muscle flap. Interact Cardiovasc Thorac Surg. 2009;8:697–8.
Yano T, Haro A, Shikada Y, et al. A unique method for repairing intraoperative pulmonary air leakage with both polyglycolic acid sheets and fibrin glue. World J Surg. 2012;36:463–7.
Lee S, Park SY, Bae MK, et al. Efficacy of polyglycolic acid sheet after thoracoscopic bullectomy for spontaneous pneumothorax. Ann Thorac Surg. 2013;95:1919–23.
Shinozaki T, Hayashi R, Ebihara M, et al. Mucosal defect repair with a polyglycolic acid sheet. Jpn J Clin Oncol. 2013;43:33–6.
Takimoto K, Imai Y, Matsuyama K. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection. Dig Endosc. 2014;26(Suppl 2):46–9.
Tsuji Y, Ohata K, Gunji T, et al. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to cover wounds after colorectal endoscopic submucosal dissection (with video). Gastrointest Endosc. 2014;79:151–5.
Doyama H, Tominaga K, Yoshida N, et al. Endoscopic tissue shielding with polyglycolic acid sheets, fibrin glue and clips to prevent delayed perforation after duodenal endoscopic resection. Dig Endosc. 2014;26(Suppl 2):41–5.
Tsuji Y, Fujishiro M, Kodashima S, et al. Polyglycolic acid sheets and fibrin glue decrease the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms (with video). Gastrointest Endosc. 2015;81:906–12.
Takimoto K, Hagiwara A. Filling and shielding for postoperative gastric perforations of endoscopic submucosal dissection using polyglycolic acid sheets and fibrin glue. Endosc Int Open. 2016;4:E661–4.
Sakaguchi Y, Tsuji Y, Yamamichi N, et al. Successful closure of a large perforation during colorectal endoscopic submucosal dissection by application of polyglycolic acid sheets and fibrin glue. Gastrointest Endosc. 2016;84:374–5.
Takahashi R, Yoshio T, Horiuchi Y, et al. Endoscopic tissue shielding for esophageal perforation caused by endoscopic resection. Clin J Gastroenterol. 2017;10:214–9.
Tsujii Y, Nishida T, Nishiyama O, et al. Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms: a multicenter retrospective cohort study. Endoscopy. 2015;47:775–83.
Shin KY, Jeon SW, Cho KB, et al. Clinical outcomes of the endoscopic submucosal dissection of early gastric cancer are comparable between absolute and new expanded criteria. Gut Liver. 2015;9:181–7.
Repici A, Hassan C, De Paula Pessoa D, et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy. 2012;44:137–50.
Toyonaga T, Man-i M, East JE, et al. 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. Surg Endosc. 2013;27:1000–8.
Inoue T, Uedo N, Yamashina T, et al. Delayed perforation: a hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig Endosc. 2014;26:220–7.
Yamamoto Y, Yoshizawa N, Tomida H, et al. Therapeutic outcomes of endoscopic resection for superficial non-ampullary duodenal tumor. Dig Endosc. 2014;26(Suppl 2):50–6.
Mori H, Fujihara S, Kobara H, et al. Successful closing of duodenal ulcer after endoscopic submucosal dissection with over-the-scope clip to prevent delayed perforation. Dig Endosc. 2013;25:459–61.
Irino T, Nunobe S, Hiki N, et al. Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection. Endoscopy. 2015;47:349–51.
Ichikawa D, Komatsu S, Dohi O, et al. Laparoscopic and endoscopic co-operative surgery for non-ampullary duodenal tumors. World J Gastroenterol. 2016;22:10424–31.
Hirajima S, Ikoma H, Ishiii H, et al. A patient with retroperitoneal abscess following ESD-related duodenal perforation. J Abdom Emerg Med. 2012;32:1103–6.
Furukawa K, Miyahara R, Funasaka K, et al. Endoscopic closure of duodenal perforation with the over-the-scope-clipping system. Intern Med. 2016;55:3131–5.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Dr. Toyonaga invented the Flush knife-BT in conjunction with Fujifilm and receives royalties from its sale.
Human and animal rights
All procedures followed have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Informed consent
Informed consent was obtained from the patient for being included in the study.
Rights and permissions
About this article
Cite this article
Ohara, Y., Takimoto, K., Toyonaga, T. et al. Enormous postoperative perforation after endoscopic submucosal dissection for duodenal cancer successfully treated with filling and shielding by polyglycolic acid sheets with fibrin glue and computed tomography-guided abscess puncture . Clin J Gastroenterol 10, 524–529 (2017). https://doi.org/10.1007/s12328-017-0791-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12328-017-0791-7