Risk factors for intraoperative perforation during endoscopic submucosal dissection of superficial esophageal squamous cell carcinoma

Table 1 Clinicopathological characteristics and procedure outcomes of the 156 esophageal squamous cell carcinomas in 147 patients n (%)

	Patients = 147, ESCC = 156
Age, median (range)	68 (46-88)
Sex
Male	131 (89.1)
Female	16 (10.9)
Lesion
Maximum dimension, median (range), mm	29 (6-68)
Location
Upper	8 (5.1)
Middle	83 (53.2)
Lower	65 (41.7)
Depth of invasion
EP	50 (32.1)
LPM	44 (28.2)
MM	37 (23.7)
SM1	8 (5.1)
SM2	17 (10.9)
Macroscopic type
0-IIc	151 (96.8)
0-IIa	3 (1.9)
0-I + IIc	2 (1.3)
Predominant site
Right	102 (65.4)
Left	54 (34.6)
Operator
Instructor	100 (64.1)
Novice	56 (35.9)
Procedure time, mean ± SD, min	107.1 ± 50.4
En block resection	141 (90.4)
Perforation	9 (5.8)
Late perforation	0 (0.0)

ESCC: Esophageal squamous cell carcinoma.

Table 2 Clinicopathological findings associated with intraoperative perforation during endoscopic submucosal dissection n (%)

	Perforated group	Non-perforated group	P value
	n = 9	n = 147
Age, mean ± SD	67.9 ± 9.7	68.1 ± 7.5	0.929
Sex
Male	9 (100)	131 (89.1)
Female	0 (0)	16 (10.9)	0.599
History of treatment for esophageal carcinoma, n (%)
Yes	0 (0)	17 (11.6)
No	9 (100)	130 (88.4)	0.599
Maximum dimension of lesion, mean ± SD, mm	42.9 ± 19.3	30.8 ± 14.1	0.016
Mucosal deficiency ≥ 75% circumference, n (%)
Yes	7 (77.8)	45 (30.6)
No	2 (22.2)	102 (69.4)	0.007
Location
Upper	0 (0)	8 (5.4)
Middle	4 (44.4)	79 (53.7)
Lower	5 (55.6)	60 (40.8)	0.697
Depth of invasion
M	6 (66.7)	125 (85.0)
SM	3 (33.3)	22 (15.0)	0.158
Predominant site
Right	4 (44.4)	98 (66.7)
Left	5 (55.6)	49 (33.3)	0.277
Operator
Instructor	6 (66.7)	94 (63.9)
Novice	3 (33.3)	53 (36.1)	1.00
Procedure time, mean ± SD, min	183.8 ± 48.7	102.4 ± 46.7	< 0.001
En bloc resection	3 (33.3)	138 (93.9)	< 0.001

Table 3 Risk factors for perforation by univariate analysis

Factor	Odds ratio1 (95%CI)	P value
Age (10 yr increments)	0.96 (0.40-2.32)	0.931
Maximum dimension of lesion (10 mm increments)	1.64 (1.07-2.52)	0.025
Mucosal deficiency (< 75% vs≥ 75% circumference)	7.93 (1.59-39.7)	0.012
Location (upper + middle vs lower)	1.86 (0.48-7.23)	0.368
Depth of invasion (M vs SM)	3.00 (0.69-12.9)	0.140
Predominant site (right vs left)	2.50 (0.64-9.72)	0.186
Operator (novice vs instructor)	1.13 (0.27-4.69)	0.869

¹Univariate logistic regression analysis. CI: Confidence interval.

Table 4 Risk factors for perforation by multivariate analysis

Factor	Odds ratio1 (95%CI)	P value
Mucosal deficiency (< 75% vs≥ 75% circumference	7.37 (1.45-37.4)	0.016
Depth of invasion (M vs SM)	2.63 (0.57-12.2)	0.218
Predominant site (right vs left)	2.33 (0.57-9.57)	0.240

¹Multivariate logistic regression analysis.

Table 5 Clinicopathological characteristics and outcomes of endoscopic submucosal dissection in perforation cases (n = 9)

Case	Age	Sex	Location	Predo-minant site	Circum-ference of tumor	Circum-ference of mucosal deficiency	Maximum dimension (mm)	Macroscopic type	Procedure time (mm)	En bloc resection	Swiching to EPMR after perforation	Depth of invasion	Perforation site
1	70	M	Middle	Right	2/3	3/4	54	0-IIc	240	No	Yes	SM2	Left
2	59	M	Lower	Left	1/2	7/8	50	0-IIc	240	Yes	No	M3	Left
3	61	M	Lower	Left	3/4	7/8	38	0-IIc	150	No	Yes	M2	Left
4	58	M	Middle	Right	1/3	1/2	30	0-IIc	140	No	Yes	SM2	Posterior > left
5	77	M	Lower	Left	3/4	7/8	67	0-IIc	210	Yes	No	M3	Anterior > left
6	61	M	Middle	Right	1/2	7/8	40	0-IIc	210	No	No	M2	Left
7	77	M	Lower	Left	1/2	3/4	32	0-IIc	150	No	Yes	M3	Left
8	85	M	Middle	Left	Circ	Circ	68	0-IIc	210	Yes	No	SM2	Left
9	63	M	Lower	Right	1/8	1/2	7	0-IIc	104	No	Yes	M1	Right

Circ: Whole circumference. EPMR: Endoscopic piecemeal mucosal resection.

Table 6 Clinical courses and treatment after perforations (n = 9)

Case	Fasting duration (d)	Hospitali-zation (d)	Maximal CRP (mg/dL)	Complication					Treatment				Local recurrence	Follow-up (mo)
				Pneumo-derma	Pneumo-thorax	Pleural effusion	Hypoxia	Fever ( °C)	Closing by clips	ABx	NG tube	Chest drain
1	8	20	26.5	−	−	+	−	38.1	Possible	+	−	+	−1	59
2	8	13	6.7	+	−	−	−	37.7	Possible	+	−	−	−	50
3	6	12	5.7	+	−	−	+	37.6	Possible	+	+	−	−	41
4	5	8	1.9	+	−	−	−	37.2	Possible	+	−	−	−2	46
5	5	7	6.9	+	−	+	−	< 37.0	Possible	+	+	−	−	42
6	19	22	16.7	+	−	+	+	38.3	Impossible	+	+	+	−	40
7	22	41	6.3	+	−	−	+	37.6	Impossible	+	+	−	−	30
8	6	9	5.5	+	−	+	+	< 37.0	Impossible	+	−	−	−2	28
9	6	9	8.8	+	−	−	+	37.8	Possible	+	+	−	−	53

¹Additional chemoradiotherapy because of submucosal infiltration;

²Additional curative surgery because of submucosal infiltration. CRP: C-Reactive protein; ABx: Antibiotics; NG tube: Nasogastric tube.