Onishi Sachiyo, Takada Jun, Otani Kiichi, Masuda Naoya, Taniguchi Hiroki, Kojima Kentaro, Kubota Masaya, Ibuka Takashi, Iwashita Takuji, Shimizu Masahito
First Department of Internal Medicine Gifu University Hospital Gifu Japan.
DEN Open. 2025 Apr 8;5(1):e70115. doi: 10.1002/deo2.70115. eCollection 2025 Apr.
Delayed perforation after esophageal endoscopic submucosal dissection is a rare complication that may result in severe outcomes. Here, we report a case of delayed perforation that was successfully managed with conservative treatment. A 72-year-old male with hypertensive renal failure and on maintenance hemodialysis underwent endoscopic submucosal dissection for a 2/3 circumferential superficial esophageal cancer in the middle thoracic esophagus, involving resection of 4/5 of the esophageal circumference. Locoregional steroid injections were administered after resection to prevent stenosis. No perforation occurred during the procedure; however, delayed perforation was identified on postoperative day 3. Endoscopy revealed necrosis and brittleness in a large area of the post-endoscopic submucosal dissection ulcer. The patient developed fever and mediastinal emphysema, and endoscopic attempts to close the perforation were unsuccessful. Conservative management-including fasting, antibiotics, and subsequent drainage-was initiated. The patient's condition improved with drainage tube placement, enteral nutrition, and antibiotic administration. A follow-up computed tomography scan on postoperative day 56 confirmed the resolution of mediastinal emphysema, and endoscopy revealed that the perforation healed with scarring. This case highlights that surgery may be avoided if appropriate treatment is initiated as early as possible, including drainage to prevent exposure to gastric and intestinal fluids, early initiation of enteral nutrition, rehabilitation to maintain strength, and blood transfusions as supportive care.
食管内镜黏膜下剥离术后延迟穿孔是一种罕见的并发症，可能导致严重后果。在此，我们报告一例通过保守治疗成功处理的延迟穿孔病例。一名72岁男性，患有高血压性肾衰竭且正在接受维持性血液透析，因中胸段食管2/3周径的浅表食管癌接受了内镜黏膜下剥离术，切除了食管周长的4/5。切除术后给予局部类固醇注射以预防狭窄。手术过程中未发生穿孔；然而，术后第3天发现延迟穿孔。内镜检查显示内镜黏膜下剥离术后溃疡大片区域出现坏死和脆性增加。患者出现发热和纵隔气肿，内镜下试图封闭穿孔未成功。于是开始采取保守治疗，包括禁食、使用抗生素及随后的引流。随着引流管置入、肠内营养和抗生素使用，患者病情改善。术后第56天的随访计算机断层扫描证实纵隔气肿已消退，内镜检查显示穿孔已瘢痕愈合。该病例强调，如果尽早开始适当治疗，包括引流以防止暴露于胃肠液、尽早开始肠内营养、康复以维持体力以及输血作为支持治疗，可能避免手术。
