Risk factors for perforations associated with endoscopic submucosal dissection in gastric lesions: emphasis on perforation type

Endoscopic submucosal dissection (ESD) enables en bloc resection of larger gastric neoplasms. However, the procedure is associated with a high incidence of perforation. Perforations during ESD are divided into macro- and microperforations. Although both types of perforations could cause widespread tissue injury and secondary sepsis, very little is known concerning the risk factors for perforations according to the type of perforation. Thus, this study was performed to evaluate the risk factors for macro-, micro-, and all perforations (both) during ESD. 823 gastric lesions (gastric adenoma or early gastric cancer) in 729 patients treated by ESD were enrolled, and their records were reviewed retrospectively. Risk factors were evaluated, focusing on age, sex, gastric neoplasm-related factors (12 locations, resected size, gross type of lesions, presence of ulceration, presence of fibrosis, pathologic diagnosis, and depth of invasion), and ESD procedure-related factors (type of knife, immediate bleeding during ESD, en bloc resection, procedure time, and the number of ESD cases experienced by the endoscopist). Of the 823 gastric lesions, the rates of all perforation, macroperforation, and microperforation were 9.6%, 7.5%, and 2.1%, respectively. Risk factors for all perforations on multivariate analysis were location of tumor in upper portion, presence of fibrosis, and long procedure time (> 2 h). Risk factors for macroperforations were the same as all perforations. Risk factors for microperforations on multivariate analysis were old age (a parts per thousand yen81 years), depth of invasion (muscularis mucosa), and long procedure time (> 2 h). The risk factors for perforations during ESD could differ according to the type of perforation. Therefore, although macroperforation did not develop during ESD, it would be necessary to consider the possibility of microperforation in case of old age, long procedure time, and (deep) depth of invasion.