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Page 14 of 20 Nakamura et al. Mini-invasive Surg 2022;6:50 https://dx.doi.org/10.20517/2574-1225.2022.38

technically demanding; however, Mori et al. developed a delivery station system and demonstrated the
[53]
feasibility of the delivery devices . A recent meta-analysis including four studies (212 lesions in the PGA
sheet group and 208 in the control group) suggested that the post-ESD bleeding rate was significantly lower
[54]
in the PGA sheet group than in the control group [4.9% vs. 13.7% (95%CI: 0.18-0.72)] . The usefulness of
endoscopic closure of a post-ESD wound to prevent post-ESD bleeding in the stomach was also
investigated. The latest multicenter RCT failed to demonstrate a significant effect of PGA sheet shielding on
the prevention of post-ESD bleeding ; thus, further investigation is warranted.
[55]

Choi et al., in their observational study, indicated that endoclip closure of post-ESD wounds significantly
reduced the delayed bleeding rate compared to that in the control group (3.3% vs. 13.3%, P = 0.04) .
[56]
However, a recent Japanese study revealed that clip and endoloop closure of post-gastric ESD ulcers did not
reduce the incidence of post-ESD bleeding (n = 311, 11.5% vs. 11.9%, P = 0.89) in patients receiving
antithrombotic therapy .
[57]

Perforations
A systematic review identified a perforation rate of 3.02% (512/16,941), and 98.8% of patients (506/512)
recovered without surgical intervention . In general, intraoperative perforation during gastric ESD is
[58]
initially managed with endoscopic clip closure. Needle paracentesis may be considered for unstable vital
signs by pneumoperitoneum. If endoscopic clip closure is difficult, other methods (over-the-scope clips
(OTSC), PGA sheet shielding, purse-string closure with endoclip-and-loop, etc.) are attempted.
Unsuccessful endoscopic closure requires surgical intervention. Delayed perforation usually requires
surgical intervention; however, endoscopic closure using OTSC or PGA sheets may be considered as a
salvage treatment [Figure 9].

Risk factors for intraoperative perforation during gastric ESD are shown in Table 5.

In terms of location, the upper third [59-65] , middle third [65,66] , greater curvature, and the remnant stomach
[67]
were reported as high-risk areas for intraprocedural perforation. Other risk factors include large tumor
size [60,62] , deep invasion [67,68] , submucosal fibrosis [67-70] , elevated morphology , and old age . Long
[68]
[67]
[61]
procedural time [63,68,71] and piecemeal resection have also been reported to be associated with the incidence
of perforation, which might be due to not only tumor-related factors but also endoscopist-related factors.
Lim et al. suggested that operators’ workload, i.e., regular endoscopy work in an outpatient clinic prior to
[72]
ESD, increased the risk of intraprocedural perforation .

A systematic review identified that the delayed perforation rate after gastric ESD was 0.19% (28/14,566),
with 50% of patients (14/28) needing emergency surgery . Several reports suggest that lesions in the gastric
[58]
tube, those in the upper stomach, and excessive electrocautery during hemostasis are associated with
delayed perforation [73-75] .

Intraoperative perforation usually develops as a linear incision of the muscularis propria and is managed
using simple clip closure. Air deflation is helpful in closing the incised perforation once a clip is applied.
The omental-patch method may be indicated for large muscular defects, especially when they are located at
the greater curvature of the gastric body . Recently, new devices and methods such as OTSC , PGA sheet
[77]
[76]
shielding [78,79] , and closure using an endoclip-and-loop [73,80] have been reported in several case studies. All
these methods could be used as a substitute when simple clip closure fails.