LAUSR

A 68-year-old woman was found to have a flat elevated lesion, which was approximately 20mm in size and located in the hepatic flexure. The patient underwent endoscopic submucosal dissection (ESD) for the lesion, and en bloc resection was achieved without intraoperative perforation (▶Fig. 1 a). A few endoclips were applied prophylactically to close tiny injuries to the muscularis propria (▶Fig. 1b). Two days after the endoscopic treatment, the patient started to experience severe lower abdominal pain and nausea, and computed tomography (CT) revealed free air (▶Fig. 2). After discussion with surgeons, it was decided to close the perforation endoscopically because there was no ascites or abscess. During colonoscopy, brown intestinal juice was observed. The ulceration from the endoscopic treatment was red and edematous, and a perforation was confirmed (▶Fig. 3 a). As the perforation was relatively large and thick, we decided to use an over-the-scope clip (OTSC, 12/6 t; Ovesco, Tübingen, Germany) in order to firmly close the whole wall defect. After suctioning the perforated part into the cap, the OTSC device was released, and the wound was closed successfully (▶Fig. 3b, ▶Video 1). The patient was discharged home 12 days after ESD. Several reports have described the feasibility of using OTSCs for delayed perforation in the upper gastrointestinal tract [1, 2]. However, delayed perforation after colonic ESD usually requires emergency surgery. In the current case, the delayed perforation was diagnosed early by CT scan, allowing the wound to be treated endoscopically and without drainage. Recent reports have described how the use of polyglycolic acid sheets and fibrin glue or endoclips has avoided emergency surgery [3, 4]. However, the opposition forces of OTSCs are much stronger and may result in a more secure closure, thus avoiding emergency surgery. Endoscopy_UCTN_Code_CPL_1AJ_2AG Competing interests