Outcomes of perforation after colorectal endoscopic submucosal dissection in a large prospective multicenter cohort

BACKGROUND : Endoscopic submucosal dissection (ESD) offers better oncological outcomes and lower recurrence rates, but is limited in colorectal use owing to concerns about adverse events, especially perforation. This study aimed to explore the clinical burden and risk factors for perforation in a Western cohort. METHODS : Analysis of intraprocedural and delayed perforations from a prospective cohort study including 3770 colorectal ESDs performed at one Belgian and 12 French centers between September 2019 and September 2022. RESULTS:  Intraprocedural perforation (n = 314; 8.3 %) or delayed perforation (n = 22; 0.6 %) occurred in 336/3770 procedures (8.9 %). Conservative management was effective for 308/336 perforations (91.7 %), especially for intraprocedural perforations (n = 304 /314; 96.8 %). Delayed perforation frequently required emergent surgery (n = 18/22; 81.8 %). Multivariable analysis identified factors associated with intraprocedural perforation, including previous resection (odds ratio [OR] 1.9, 95%CI 1.3 to 2.7), lesion size ≥ 50 mm (OR 1.5, 95%CI 1.2 to 1.9), poor maneuvrability (OR 2.0, 95%CI 1.4 to 2.5) and severe fibrosis (OR 4.4, 95%CI 3.2 to 6.1). Proximal colonic location and severe fibrosis were associated with increased risk of delayed perforation. A perforation ≥ 5 mm (OR 8.9, 95 %CI 1.0 to 76.5) and fever (OR 9.5, 95 %CI 2.4 to 38.0) or abdominal pain (OR 26.6, 95 %CI 3.3 to 213.8) were associated with surgery after intraprocedural perforation (univariable analysis). No deaths were directly linked to perforation, but one death occurred due to delayed bleeding. CONCLUSIONS:  ESD-related perforations are often manageable conservatively, with surgery being rare; however, delayed perforations remain challenging and often require surgery. Patients should be informed of both the benefits and risks.