Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy:A pilot study

BACKGROUND Endoscopic papillectomy(EP)is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients.With the expansion of indications,concerns regarding EP include not only technical difficulties,but also the risk of complications,especially delayed duodenal perforation.Delayed perforation after EP is a rare but fatal complication.Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP.Draining bile and pancreatic juice away from the wound may help to prevent delayed perforation.AIM To evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.METHODS This is a single-center,retrospective study.Five patients with exposure or injury of the muscularis propria after EP were included.A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent,modified by an endoscopic nasobiliary drainage tube,were placed in the common bile duct and pancreatic duct,respectively,and the bile and pancreatic juice were drained to the proximal jejunum.RESULTS EP and overlength stents placement were technically feasible in all five patients(63±12 years),with an average operative time of 63.0±5.6 min.Of the five lesions(median size 20 mm,range 15-35 mm),four achieved en bloc excision and curative resection.The final histopathological diagnoses of the endoscopic specimen were one tubular adenoma with high-grade dysplasia(HGD),one tubulovillous adenoma with low-grade dysplasia,one hamartomatous polyp with HGD,one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma,HGD and field cancerization invading the muscularis mucosae and submucosa.There were no stent-related complications,but one papillectomy-related complication(mild acute pancreatitis)occurred without any episodes of bleeding,perforation,cholangitis or late-onset duct stenosis.CONCLUSION For patients with exposure or injury of the muscularis propria after EP,the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.

Delayed perforation after endoscopic resection of a colonic laterally spreading tumor:A case report and literature review

BACKGROUND Endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)have been widely used for the treatment of early gastrointestinal cancer.Endoscopic piecemeal mucosal resection(EPMR)is derived from the combination of EMR and ESD.Delayed perforation with peritonitis after colonic EPMR is a rare but severe complication,sometimes requiring surgery.There are some associated risk factors,including patient-(location,diameter,and presence of fibrosis)and procedure-related factors.Early recognition and timely treatment are crucial for its management.CASE SUMMARY We report a case in which delayed perforation with peritonitis was treated using endoscopic closure.A 54-year-old man was diagnosed with a 30-mm-diameter laterally spreading tumor in the colonic hepatic curvature.Fifteen hours after endoscopic resection,peritonitis caused by delayed perforation occurred and gradually aggravated.Conservative treatment was ineffective and no obvious perforation was observed.After timely endoscopic closure,the patient was discharged on postoperative day 4.CONCLUSION In occasion of localized peritonitis aggravating without macroscopic perforation,endoscopic closure is an effective treatment for delayed perforation with stable vital signs in the early stage.

Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report

BACKGROUND Acute iatrogenic colorectal perforation(AICP)is a serious adverse event,and immediate AICP usually requires early endoscopic closure.Immediate surgical repair is required if the perforation is large,the endoscopic closure fails,or the patient's clinical condition deteriorates.In cases of delayed AICP(>4 h),surgical repair or enterostomy is usually performed,but delayed rectal perforation is rare.CASE SUMMARY A 53-year-old male patient underwent endoscopic submucosal dissection(ESD)at a local hospital for the treatment of a laterally spreading tumor of the rectum,and the wound was closed by an endoscopist using a purse-string suture.Unfortunately,the patient then presented with delayed rectal perforation(6 h after ESD).The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery(TEM);however,the perforation worsened and became enlarged,multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred,and the internal anal sphincter was damaged.As a result,the perforation became more complicated.Due to the increased bleeding,surgical treatment with suturing could not be performed using TEM.Therefore,the patient was sent to our medical center for follow-up treatment.After a multidisciplinary discussion,we believed that the patient should undergo an enterostomy.However,the patient strongly refused this treatment plan.Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared,we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent(SECMS)in combination with a transanal ileus drainage tube(TIDT).CONCLUSION For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation,a SECMS combined with a TIDT can be used and may result in very good outcomes.

ESOPHAGUS-STOMACH-ABDOMINAL WALL DRAINAGE FOR DELAYED INTRATHORACIC ESOHPAGEAL PERFORATION

Objective To design a technique of esophagus-stomach-abdominal wall drainage for the de-layed intrathoracic esophageal perforation and to improve the therapeutic results. Methods Four patients were treated by this simplified technique. There were 1 case of lower intrathoracic esophageal perforation to the left thorax , 1 high and 2 middle perforation to the right. This technique used two plastic tubes (chest tube) in a diameter about 1 .2cm . One tube served as an intercostal drainage tube to drain purulent effusion , the other was inserted abdominally through stomach to the esophagus about 10cm above the esophageal perforation. Results The four patients were treated successfully by the esophagus-stomach-abdominal wall drainage. There was no mortality or severe morbidity or complication. Hospitalizations were shortened. Conclusion This technique is simple, safe and effective. It may provide a more promising alternative method of treatment for delayed esophageal perforation, especially in the critically ill patients. The procedure can also be extended to deal with esophagus-stomach anastomotic leak.

Endoscopic transgastric drainage of a gastric wall abscess after endoscopic submucosal dissection

A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer.Endoscopic submucosal dissection(ESD)was successfully performed for complete resection of the tumor.On the first post-ESD day,the patient suddenly complained of abdominal pain after an episode of vomiting.Abdominal computed tomography(CT)showed delayed perforation after ESD.The patient was conservatively treated with an intravenous proton pump inhibitor and antibiotics.On the fifth post-ESD day,CT revealed a gastric wall abscess in the gastric body.Gastroscopy revealed a gastric fistula at the edge of the post-ESD ulcer,and pus was found flowing into the stomach.An intradrainage stent and an extradrainage nasocystic catheter were successfully inserted into the abscess for endoscopic transgastric drainage.After the procedure,the clinical symptoms and laboratory test results improved quickly.Two months later,a follow-up CT scan showed no collection of pus.Consequently,the intradrainage stent was removed.Although the gastric wall abscess recurred 2 wk after stent removal,it recovered soon after endoscopic transgastric drainage.Finally,after stent removal and oral antibiotic treatment for 1 mo,no recurrence of the gastric wall abscess was found.

Prevention of late complications of endoscopic resection of colorectal lesions with a coverage agent:Current status of gastrointestinal endoscopy

Endoscopic ectomy of large nonpedunculated colorectal lesions(≥20 mm)might cause significant adverse incidents,such as delayed perforation and delayed bleeding,despite the closure of mucosal lesions with clips.The conventional utilization of prophylactic clipping has not decreased the risk of postprocedural delayed adverse events,and additional outcomes and cost-effectiveness research is needed for patients with proximal lesions≥20 mm,in whom prophylactic clipping might be useful.Coverage of the wound after endoscopic excision offers shield protection against delayed concomitant diseases.