Slide 2 Backgroud
ESD using various knives make it possible to perform en
bloc resections of larger early stage gastric cancers with a reduction in the lesion recurrence rate
But, it takes long time to perform the procedure
and to become the expert .
Relatively complication rate (ex: perforation, bleeding, others) is high
Before the beginner endoscopist start to perform this procedure, how to manage complication is essential
Slide 3 Materials
Major complications of ESD are bleeding, perforation and others.
We tried three kinds of methods for bleeding control (hemostasis) such as
1) Direct coagulation c knives
2) Hemostasis using hemostatic forceps
These three methods applied in order
To make closure of perforation, we tried three kinds of methods such as
1) Direct closure c clipping
2) Omental patch method
3) Combine method using clip & detachable snare.
Today I will show you some cases of bleeding, perforation and other complication and explain how to manage them.
Slide 4 Cases
During marginal cutting, bleeding was happened.
I recommend step by step approach. As I mentioned
I tried direct coagulation with knifes. To find exact bleeding point, I made saline irrigation and check bleeding focus and coagulate with knives by soft coagulation.
After coagulation, we can find complete hemostasis.
Next method is using hemostatic forceps.
You can find blood vessel and so to prevent bleeding, I tried using IT knife with coagulation power. But it made bleeding again. After making water irrigation, find bleeding focus and grasp the bleeding focus with hemostatic forcpes then lift up slightly and use soft coagulation. Finally I performed a complete hemostasis
Clipping is final choice for hemostasis because clipping prohibit additional dissection.
After failing direct coagulation and hemostatic forceps, I tried clipping for hemostasis.
In this case,
when I tried marginal cutting with a needle knife, as you can see, you can find perforated area and a moving large bowel.
I use endoscopic clipping (or with) normal mucosa and submucosa around the perforated area.
To make better. vision of the remaining perforated area, I needed additional submucosal dissection. Now it is available to check remaining perforated area again. I tried clipping again.
I successfully finished an endoscopic closure.
If patient's abdomen is fully distended, patient can suffer from severe discomfort.
In this case, I had to make direct puncture with needle into peritoneal cavity.
To check the drainage of air, angio needle is connected with IV line which is put into a water bottle. And then we can find airbubble from the patient's abdomen in water bottle.
After decompression, Simple abdomen showed decreased volume of free air.
Slide 9 : In this case,
during submucosal dissection, you can find a big perforation hole (injected serosa).
To make endoscopic closure, I tried single closure method with a clip.
To avoid delayed perforation which can happen during the perforation of the big area, endoloop is placed, thereby closing the perforation.
Using two channel endoscope, I put a clip device into one accessory channel, and a detachable snare (endoloop) into the other one.
I hold one side of an endoloop with a clip and the other side with another clip as well. And then slowly pulling back the endoloop, the big perforated hole is closed.
Slide 10 : During marginal cutting, in this case, we can find a perforated hole and omental fat in the outside of a stomach.
First, I tried clipping for closure of the perforated area.
That night, the patient had suffered from peritoneal irritation sign, so I checked follow-up endoscopic exam.
You can find a big perforated hole again where the perforation was found the day before.
I tried omental patch method but failed.
This patient is the only one whom I sent to the operating room.
In the operating room, I attended the patient's surgery.
His abdominal cavity had lots of adhesion bands because of previous cholecystectomy.
This was the reason why omental patch method wa failed.
In this patient, endosocpic finding shows pyloric stenosis 2months after ESD on pyloric ring area.
I tried balloon dilatation. As you can see, I put the guidewire and ballon catheter into stenotic area and fully dilatated.
Under fluoroscopic image, unfolding of the notching area can be seen.
You can find dilatated stenotic portion.
After finishing balloon dilatation, scope can go to duodenal 2nd portion.
12 months later, patient did not complain about any symptom.
In summary, we performed about 99.2% of complete hemostasis with three methods.
We successfully made about 84.4% of complete closure of the perforated area.
Three cases of pyloric stenosis were treated by balloon dilatation and stenting.
If you know how to manage complication well enough before starting ESD,
Overcoming complication is possible.
Chang Beom Ryu, MD, PhD, Soon Chun Hyang University Hospital, Bucheon
In Seop Jung, MD, Soon Chun Hyang University
Bong Min Ko, MD, Soon Chun Hyang University Hospital, Bucheon
Su Jin Hong, MD, Soon Chun Hyang University Hospital, Bucheon
Joo Young Cho, MD, Soon Chun Hyang University Hospital, Bucheon
Jong Sung Lee, MD, Soon Chun Hyang University Hospital, Bucheon
Mong Sung Lee, MD, Soon Chun Hyang University Hospital, Bucheon
Chan Sup Shim, MD, Soon Chun Hyang University Hospital, Bucheon
Boo Sung Kim, MD, Soon Chun Hyang University Hospital, Bucheon