Clinical risk factors for perforation during endoscopic submucosal dissection (ESD) for large-sized, nonpedunculated colorectal tumors.

Background: The possible risk of colonic perforation during endoscopic submucosal dissection (ESD) for colorectal tumors is a barrier to wide application. This retrospective study was performed to evaluate the risk and the predictive factors for perforation during ESD procedure.

Methods: Between October 2006 and November 2010, a total of 499 consecutive patients (mean age 60.0 ± 11.3 years) who underwent ESD for large-sized (≥ 20 mm), nonpedunculated colorectal tumor were analyzed. First, incidence rate and clinical course of perforation were evaluated. Second, patient-related variables (age, sex, history of aspirin or antiplatelet agents, and comorbidity), endoscopic variables (tumor size, location, and type), procedure-related variables (experience of procedures, procedure time, and materials of submucosal injection), and pathologic diagnosis were analyzed.

Results: The mean size of the lesions was 28.9 mm. The overall en bloc resection rate was 95.0%. Perforation occurred in 37 out of 499 patients (7.4%). Thirty-four patients could be successfully treated conservatively. The type (laterally spreading tumor) and the location (right-sided colon) of the tumors, less experience of the procedure (<100 cases) in each endoscopist, and submucosal injection without hyaluronic acid were associated with higher frequency of perforation (all P < 0.05). On multivariate analysis, laterally spreading type of tumor [odds ratio (OR) 4.10, 95% confidence interval (CI) 1.17-14.34] and submucosal injection with hyaluronic acid (OR 0.31, 95% CI 0.13-0.72) were independent predictive factors.

Conclusions: Perforation rate was 7.4%, and most cases could be successfully managed nonsurgically. In case of laterally spreading type of tumor, more caution is needed during submucosal dissection and long-lasting submucosal cushion is important for preventing perforation.