Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: A prospective pilot study

Abstract

Aim: To evaluate clinical outcomes and risk factors for endoscopic perforation during endoscopic submucosal dissection (ESD) in a prospective study.

Methods: We investigated the clinical outcomes and risk factors for the development of perforation in 98 consecutive gastric neoplasms undergoing ESD regarding. Demographic and clinical parameters including patient-, tumor-, and treatment-related factors, clinical parameters, and duration of hospital stay were analyzed for risk factors for perforation. In subgroup analysis, we also compared the clinical outcomes between perforation and "silent" free air without endoscopically visible perforation detected only by computed tomography.

Results: Perforation was identified in 8.2% of patients. All patients were managed conservatively by the administration of antibiotics. The mean procedure time was significantly longer in patients with endoscopic perforation than in those without. According to the receiver-operating characteristic analysis, the resulting cutoff value of the procedure time for perforation was 115 min (87.5% sensitivity, 56.7% specificity). Prolonged procedure time (≥ 115 min) was associated with an increased risk of perforation (odds ratio 9.15; 95%CI: 1.08-77.54; P = 0.04). Following ESD, body temperature and C-reactive protein level were significantly higher in patients with perforation than in those without (P = 0.02), whereas there was no difference between these patient groups on the starting day of oral intake or of hospitalization. In subgroup analysis, the post-ESD clinical course was not different between endoscopic perforation and silent free air.

Conclusion: Only prolonged procedure time (≥ 115 min) was significantly associated with perforation. The clinical outcomes of perforation are favorable and are comparable to those of patients with or without silent free air.

Keywords: Endoscopic submucosal dissection; Gastric cancer; Perforation; Risk factors; Treatment outcome.

Figures

Figure 1

Clinical protocol of endoscopic submucosal dissection. ESD: Endoscopic submucosal dissection; CT: Computed tomography.

Figure 2

Receiver-operating characteristic curve of perforation development after endoscopic submucosal dissection. The curve is plotted with sensitivity (y-axis) and (1-specificity) (x-axis). The resulting cut-off value of the procedure time for perforation was 115 min (sensitivity, 87.5%; specificity, 56.7%).