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Video of Issue Perforation due to gag reflex during endoscopic submucosal dissection of entire circumferential superficial esophageal cancer
Kumi Itamiorcid, Takaaki Yoshikawaorcid, Shujiro Yazumiorcid

DOI: https://doi.org/10.5946/ce.2025.025
Published online: April 25, 2025

Department of Gastroenterology and Hepatology, Medical Research Institute Kitano Hospital, Osaka, Japan

Correspondence: Takaaki Yoshikawa Department of Gastroenterology and Hepatology, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, 2-4-20, Ohgimachi, Kita-ku, Osaka 530-8480, Japan E-mail: tk_yoshi@kuhp.kyoto-u.ac.jp
• Received: January 20, 2025   • Revised: February 4, 2025   • Accepted: February 5, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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A 74-year-old woman was admitted to our hospital for endoscopic submucosal dissection (ESD) of superficial esophageal cancer. The circumferential lesion was 5 cm in length and located in the lower third of the esophagus, 2 cm from the esophagogastric junction (Fig. 1). Continuous transvenous midazolam was administered during the ESD. A mucosal incision was performed, and most of the submucosal dissection was completed from the oral side (Video 1). However, midazolam did not maintain a sufficient depth of sedation during the final phase. When the endoscope was pushed into the stomach for air suction, a gag reflex was induced, leading to perforation in the preserved mucosal layer. An attempt to close the perforation with a reopenable clip further exacerbated the muscular defect because of the clip’s nail. Therefore, resection was completed quickly, and a polyglycolic acid sheet and fibrin glue were used to fill the defects. Finally, triamcinolone was injected into the post-ESD ulcers. Computed tomography revealed air and fluid in the mediastinum. However, the patient’s condition improved with conservative treatment, including antibiotics and fasting. Esophagogastroduodenoscopy on postoperative day 15 revealed a stricture at the ulcer site and obstruction of the polyglycolic acid sheet (Video 2). The sheet was successfully removed using a hot snare. Balloon dilation and oral prednisolone (30 mg) were initiated; the patient was discharged on postoperative day 34. Balloon dilation was performed five times; prednisolone was tapered over 3 months. No recurrence of malignancy or obstructive symptoms was observed for more than 1 year (Fig. 2). Perforation due to a gag reflex during esophageal ESD is very rare.1 This case highlights the high risk of perforation due to insufficient sedation2 and significant mucosal deficiency (>75%).3 Adequate sedation is essential; once a perforation occurs, protective closure methods should be used. Written informed consent was acquired from the patient.
Video 1. Perforation during esophageal endoscopic submucosal dissection.
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Video 2. Removal of a polyglycolic acid sheet and balloon dilation.
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A video related to this article can be found online at https://doi.org/10.5946/ce.2025.025.
Fig. 1.
(A) Narrow-band imaging showed an entirely circumferential brownish area at 31–36 cm from the incisors. (B) Perforation (arrows) was revealed in the carefully dissected area. (C) When perforation closure was attempted using a clip, the clip’s nail enlarged the perforation (arrows). (D) Polyglycolic acid sheet and fibrin glue were applied to the perforation.
ce-2025-025f1.jpg
Fig. 2.
Perforation was completely closed within the post-endoscopic submucosal dissection scar.
ce-2025-025f2.jpg
  • 1. Kitagawa D, Kanesaka T, Ishihara R. Esophageal rupture during endoscopic submucosal dissection closed using a novel suturing device. Dig Endosc 2023;35:e131–e133.ArticlePubMed
  • 2. Song BG, Min YW, Cha RR, et al. Endoscopic submucosal dissection under general anesthesia for superficial esophageal squamous cell carcinoma is associated with better clinical outcomes. BMC Gastroenterol 2018;18:80.ArticlePubMedPMCPDF
  • 3. Noguchi M, Yano T, Kato T, et al. Risk factors for intraoperative perforation during endoscopic submucosal dissection of superficial esophageal squamous cell carcinoma. World J Gastroenterol 2017;23:478–485.ArticlePubMedPMC

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      Perforation due to gag reflex during endoscopic submucosal dissection of entire circumferential superficial esophageal cancer
      Image Image
      Fig. 1. (A) Narrow-band imaging showed an entirely circumferential brownish area at 31–36 cm from the incisors. (B) Perforation (arrows) was revealed in the carefully dissected area. (C) When perforation closure was attempted using a clip, the clip’s nail enlarged the perforation (arrows). (D) Polyglycolic acid sheet and fibrin glue were applied to the perforation.
      Fig. 2. Perforation was completely closed within the post-endoscopic submucosal dissection scar.

      Fig. 1.

      Fig. 2.

      Perforation due to gag reflex during endoscopic submucosal dissection of entire circumferential superficial esophageal cancer
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