Factors predicting perforation during endoscopic submucosal dissection for gastric cancer

Background: Perforation is a common complication of endoscopic submucosal dissection (ESD), but little is known about the relevant risk factors. Objective: To investigate the risk factors for perforation. Design: Retrospective study. Setting: A cancer referral center. Patients: A total of 1795 early gastric tumors in 1500 patients treated by ESD from July 2002 to December 2010 were included in the analysis. Main Outcome Measurements: The associations between the incidence of perforation and patient and lesion characteristics were investigated. Results: Perforation during ESD occurred in 50 lesions (2.8%). Univariate analysis identified tumor location (upper, middle, or lower stomach), tumor diameter (≤20 or >20 mm), and treatment period (lesions treated in the first or second period) as predictors of perforation. Multivariate analysis identified tumor location (upper stomach), tumor diameter (>20 mm), and treatment period (first half) as independent risk factors for perforation. The odds ratios were 2.4 (95% CI, 1.3-4.7; P =.006) for lesions in the upper stomach and 1.9 (95% CI, 1.0-3.5; P =.04) for lesions larger than 20 mm. Perforation risks were 5.4% for lesions in the upper stomach and 4.4% for lesions larger than 20 mm. Three patients required emergency surgery, but the rest of the patients were successfully treated with endoscopic clipping. There was no perforation-related mortality. Limitations: Single-center, retrospective study design. Conclusions: Lesions in the upper stomach and lesions larger than 20 mm were independent risk factors for perforation during ESD. Patients should be made aware of the estimated high risks of these lesions before undergoing ESD.