Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer

Since being developed and established in Japan, endoscopic submucosal dissection (ESD) has been widely used as a standard treatment for early gastric cancer [1]. Delayed perforation is an occasional complication of ESD, and despite its low incidence, it is a serious complication frequently requiring emergency operation [2–4]. Polyglycolic acid (PGA) sheets (Neoveil; Gunze Co., Japan), composed of bioabsorbable material, can be used to strengthen the ulcer floor after ESD [5]. We report the successful use of PGA sheets as a conservative treatment for delayed perforation. A 62-year-old man had early gastric cancer located in the posterior wall of the upper stomach. ESD was completed in 31 minutes with no complications or perforations (●" Fig.1). On postoperative day (POD) 1, the patient was allowed to resume water intake. However, on POD 2, because of a fever as high as 39°C and a complaint of persistent epigastric pain, abdominal radiography was performed and revealed free air beneath the diaphragm. Esophagogastroduodenoscopy (EGD) on the same day revealed a 7-mm perforation and thin ulcer floor (●" Fig.2a) with unsuccessful endoclip closure, resulting in a tear in the ulcer floor owing to the fragile nature of the tissue after 2 days of inflammation. We therefore cut a PGA sheet (●" Fig.2b) into strips and placed them on the site of perforation (●" Fig.2b). After shielding with PGA sheets, complaints subsided on POD 3. Complete coverage of the perforation site with PGA sheets was confirmed by EGD on POD 7 (●" Fig.3a), and the sheets had peeled off spontaneously by POD 13, revealing a completely healed perforation site (●" Fig.3b). Scarring of