Intra-Abnominal Air Recognized By Computed Tomography After Endoscopic Submucosal Dissection with Gastric Lesions

Abstract

Introduction: Endoscopic submicosal dissection (ESD) has been established as a new treatment for gastrointesitinal lesions. However, it also has disadvantaged such as higher technical difficulty and risk of perforation or bleeding. We experienced the finding of small and focal air close to the stomach by computrd tomography (CT) after ESD, and defined it as “intra-abdominal microperforation”. Aims and Methods: Two hundred and thirty consecutive cases with gastric lesion resected by ESD, between January, 2006 and July, 2008 in our constitution. They received CT scan and blood test shortly after ESD. The lesions were 193 early gastric cancers, 32 adenomas, 2 carcinoids and 2 hyperplastic polyps. Male to female ratio was 169: 61. The mean age was 71 years old (range 29-91). Lesion locations were U: 41/M: 86/L: 100/remaining stomach: 3 cases (Lesion location was categorized into upper third of stomach (“U”), middle third (“M”), and lower third (“L”), based on the Japanese classification of gastric carcinoma). We compared the outcome and clinical significance of intra-abnominal microperforation with gastric lesion. Results: Visible perforation during ESD occurred in two cases (0.9%) and delayed perforation occurred in one case (0.4%). Twenty nine cases had intra-abdominal microperforation (12.6%). We compared the group of intra-abdominal microperforation with the negative group. There was significant differences in the size of resected specimen, the duration of operation and the incidence of pyrexia(above 37.5 degrees after ESD), while there was no significant difference in the age, hospitalization, leukocyte count and C-reactive protein within 3 days postoperatively. No serious complication was observed in the case of perforation and intra-abdominal microperforation, respectively. The positive-cases could be classified into two types; those with microperforation completely distant from stomach (TypeA, 8 cases) and those with microperforation confined in the wall of the stomach under serosa (TypeB, 19 cases). In comparision between 2 types, there was no significant difference in either parameter (the age, the size of resected specimen, the duration of operation, hospitalization, pyrexia, the endoscopic findings at the end of ESD procedure, leukocyte count and C-reactive protein within 3 days postoperatively). Conclusion: We considers that pyrexia with longer time of treatment and larger size of resected specimen are predictors of intra-abdominal microperforation but it is difficult to predict intra-abdominal microperforation after ESD with endoscopic findings. The cases with microperforation did not develop serious complications.