jcoloproctol(rioj).2014;34(4):265–268
Journal
of
Coloproctology
w w w . j c o l . o r g . b r
Case
report
Pneumoretroperitoneum,
pneumomediastinum
and
subcutaneous
emphysema
after
endoscopic
submucosal
dissection
of
a
rectal
lateral
spreading
tumor
Matheus
M.M.M.D.E.
Meyer
∗,
Geraldo
M.G.
Cruz,
Diego
V.
Sampaio,
David
De
Lanna,
Luciana
M.P.
Costa,
Ricardo
G.
Teixeira,
Fernando
J.C.
Lavall
Junior,
Daniel
A.
Zanetti,
Roberta
G.S.
Lopes,
Nayara
S.R.
Jardim,
Eloah
G.
Lima
ColoproctologyService,SantaCasadeBeloHorizonte,BeloHorizonte,MG,Brazil
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r
t
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c
l
e
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n
f
o
Articlehistory: Received6July2014 Accepted11August2014 Availableonline22October2014
Keywords:
Lateralspreadingtumor Pneumoretroperitoneum Pneumomediastinum Pneumoperitoneum
Endoscopicsubmucosaldissection
a
b
s
t
r
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c
t
Introduction:Endoscopicsubmucosaldissection(ESD)isanalreadyestablishedprocedurein thetreatmentofgastricandesophagealcancerinitsearlystages.Colorectallesions, ini-tiallyapproachedbyendoscopicmucosalresectionenblocorinfragments,arethecurrent focusforsubmucosalapproach,especiallyforsuperficiallateralspreadingtumorof20 mm-diameter.TheexperienceofJapanesecenters,whicharereferenceintherapeuticendoscopy, demonstratesreductionintherateofdiseaserecurrencewiththisapproachand, accord-ingtospecifichistopathologicalcriteria,mayavoidcolectomyinsomecasesofmalignant neoplasia.1–3
Casereport:Thepatientwas50-year-oldfemale.Sheunderwentendoscopicsubmucosal dissectionofarectallateralspreadingtumormeasuring50mm,located8cmfromtheanal margin.Theprocedurewasperformedwithoutmajorcomplications,withjusttwopointsfor musclelayerdetachment,withoutgrossperforationandclosedwithmetalclips.However, thepatientdevelopedairleakagetotheperitoneum,retroperitoneum,mediastinumand subcutaneoustissue,beingonlytreatedwithclinicalproceduresandwithoutadditional intervention.
Conclusion: ItisvitaltoknowandbeabletoapplythetechniqueofESD,inadditionto addressingitscomplications,sincedespitethenumerousbenefitscomparedtosurgery, ESDcanresultinseriousoutcomes.4,5
©2014SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
∗ Correspondingauthor.
E-mail:[email protected](M.M.M.M.D.E.Meyer).
http://dx.doi.org/10.1016/j.jcol.2014.08.008
266
jcoloproctol(rioj).2014;34(4):265–268Pneumorretroperitônio,
pneumomediastino
e
enfisema
subcutâneo
após
dissecc¸ão
endoscópica
da
submucosa
de
lesão
retal
de
crescimento
lateral
Palavras-chave:
Lesãodecrescimentolateral Pneumorretroperitôneo Pneumomediastino Pneumoperitôneo Dissecc¸ãosubmucosa endoscópica
r
e
s
u
m
o
Introduc¸ão: Adissecc¸ãoendoscópicadasubmucosa(ESD)jáéprocedimentoconsagrado notratamentodocâncergástricoeesofagianoemsuasfasesprecoces.Aslesões colorre-tais,inicialmenteabordadaspormucossectomia,emblocoouemfragmentos,sãoofoco atualparaaabordagemsubmucosa,principalmenteparaostumoresdecrescimentolateral superficialapartirde20mmdediâmetro.Aexperiênciadecentrosjaponeses,referências emendoscopiaterapêutica,demonstramreduc¸ãonoíndicederecidivadadoenc¸acomesta abordageme,segundocritérioshistopatológicosespecíficos,podemevitarumacolectomia emalgunscasosdeneoplasiamaligna.1–3
Relatodecaso: Trata-sedepacientede50anos,submetidaàdissecc¸ãoendoscópicada sub-mucosadelesãodecrescimentolateral,com50mm,localizadanoreto,a8cmdamargem anal.Oprocedimentofoirealizadosemmaioresintercorrências,comapenasdoispontos deafastamentodamuscular,semperfurac¸ãogrosseira,fechadoscomclipe.Entretanto,a pacienteevoluiucomescapeaéreoparaperitônio,retroperitônio,mediastinoesubcútis, sendotratadasemintervenc¸ãoadicional,apenascommanejoclínico.
Conclusão: ÉdefundamentalimportânciaconheceresaberaplicaratécnicadaESD,além deabordarsuascomplicac¸ões,umavezque,mesmorepletadebenefíciosemrelac¸ãoà cirurgia,elapodeapresentardesfechosgraves.4,5
©2014SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
Introduction
Colonoscopyiswidelyusednotonlyasadiagnostic proce-dure,butalsowithatherapeuticgoal,beingmuchprizedby minimallyinvasivemedicine.
ESDofearlyesophagealandgastriccarcinomasisalready practiced worldwide. The same technique applied to not-invasive pre-malignant and malignant colorectal lesions is notyetaccepted asstandard procedure.Butthisprocedure is becoming increasingly feasible, to the extent that the technology extends the capabilities with tools appropriate tothis procedure.1–3 Thus,ESDallowsthe required
profes-sionaltrainingforaproperaccomplishmentofthemethod. Despitetheprolongedsurgicaltimeandlonglearningcurve, thismethodissuperiortothepiecemealmucosal resection andhasalowerrateoflocalrecurrenceandgreaterhealing potential,besidesallowingahistopathologicdiagnosisforan accuratediseasestaging.4,5
Theperforationsandbleedingaremorecommon inthis technique;butthusfarthebenefitsconferredtothepatient outweightherisks.Moreover,theliteratureshowsthat con-servativetreatmentofthesecomplicationshasbeenpossible inmostcases.6,7
Case
report
A50-year-oldfemalepatientwasexaminedandwhoreported abdominalcrampingpaininhypogastrium,diarrhea alternat-ingwithnormalbowel habitandhematocheziaforabout a year.Theterminalileumcolonoscopyshowedatype-IIhigh
granularflat lesion,locatedabout 8cmfrom theanal mar-gin,measuring50mminitsgreatestdiameter.Ourhospital didnothavetheneededequipmentforcolonoscopyimaging magnification.
Thepatient washealthy,withcriteriaforcureofbreast adenocarcinomatreatedwithleftmastectomy,ipsilateral axil-larylymphadenectomyandadjuvanttreatmentwithradiation and chemotherapy18 yearsago.Shereportedafamily his-tory ofcolorectal cancer ina first-degree relative (mother, age70).
The patient was submitted to a colonoscopywith sub-mucosal dissectionofthe lesion undergeneralanesthesia. Submucosalinfiltrationwithglycerol12%stainedwithindigo carmineforsubmucosalexpansionandforbetter visualiza-tionofplanesandvesselswasperformed.Duringdissection, 0.1%carboxymethylcellulosewasused,inordertokeepfor longerthesubmucosalexpansion.Themusclelayer detach-ment was identified at two points; there was no gross perforation,withthebiggestonemeasuringabout8mm.Both perforationswereclosedwithmetalclips,withoutsubsequent intercurrences(Fig.1).
jcoloproctol(rioj).2014;34(4):265–268
267
Fig.1–(A)Indigocarmine-stainedLST;(B)dissection;(C)totallyresectedlesionshowingpointsofmusclelayerdetachment; (D)closurewithmetalclips.
Fig.2–Chestradiography;subcutaneousemphysema, pneumoperitoneumandpneumomediastinum.
Thepatientwastransferredtotheintensivecareunitin ambientairformonitoring.Atthattime,shewasalertand oriented.The patient remained NPO during 48h and with intravenous antibiotic therapy. The computed tomography forcontrol,performedin48h,showedpneumomediastinum, pneumoperitoneum,pneumoretroperitoneum,air delamina-tionofrectalwallsandminimumamountofperihepaticfree fluidandoffluidamongbowelloops(Fig.3).
Thepatientremainedclinicallyasymptomaticandstable. Therefore, we proceeded withconservative treatment. The patienttoleratedarestrictedliquiddietbythethirddayafter theprocedure;onthefifthday,thepatientreceivedabland diet. On the fourth day, she produced soft stools without rightred bloodormucus,and wasdischargedonthesixth dayofprogression.Attheoutpatientvisit,15daysafterthe procedure, the patient was clinicallywell and reported no complicationsinthisperiod.
Thehistopathologicalexaminationofthesamplerevealed tubulovillousadenomawithlow-gradedysplasiaandfociof high-gradedysplasia.
Discussion
The literature reports several cases of pneumoperitoneum during ESD and an increasing number ofair leakageinto the abdominalretrocavityinrectal endoscopicapproaches. Anatomically,thisspaceiscontiguouswiththemediastinum andthesubcutaneousspace.8,9
Inourcase,thenon-occurrenceofagrossperforation(as inotherreports)isinteresting,butonlythedivulsionof circu-larmusclefibers.Evenso,metalclipswereapplied,butthis wasenoughfortheairleak.Itisveryimportanttonotethat theinsufflationofcarbondioxide(CO2)islessharmfultothe patient, bybeinganeasilyabsorbedand rapidlyeliminated gas,unliketheambientair.10Unfortunatelythistechnologyis
notavailableinourservice.
268
jcoloproctol(rioj).2014;34(4):265–268Fig.3– (A)pneumomediastinum;(B)pneumoretroperitoneum,pneumoperitoneumandsubcutaneousemphysema.
tothelocationofthelesion,but withitssizeandthe pres-enceoffibrosis.Clampsofcoagulationaretheprimarycause ofperforation.11Theperforationsiteshouldbeclippedonce
ithasbeenidentified;andinpresenceofabdominal disten-tion,paracentesisdecompressionshouldbeperformed.Inour case,thisprocedurewasnotnecessary,sinceattheendofthe procedurethepatienthadaflabbyandpainlessabdomen.12
Somecasesofperforationarenotdetectedbyendoscopy,but onlyuponthecontrolradiographorCT.Mostperforationsare treatedconservatively.13
Despite technical difficulties and an extensive learning curve,ESDshouldbeencouraged,becausetheultimategoal is the reduction of sequels left by other more vigorous approachestocancer.
Conclusion
InESD-treatedpatients,microperforationscanbetreatedby conservativeprocedures,providedthatthehospitalcountona full-timemultidisciplinaryteamandpropaedeuticand thera-peuticcare,includingateamforimmediatesurgicalapproach incaseofadversedevelopments.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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