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cially for treatments that carry a high risk of perforation [3]. Early identification Paracentesis for successful treatment of tension and prompt treatment with needle de- pneumoperitoneum related to endoscopic sub- compression are important in order to avoid serious sequelae such as abdominal mucosal dissection compartment syndrome leading to multi- ple organ failure [4].

Acknowledgment Fig. 1 Abdominal ! computed tomography showed a large pneu- This work was supported in part by the moperitoneum causing Grant-in-Aid for Cancer Research (18S-2, collapse of the inferior H18–005) from the Ministry of Labour vena cava. and Welfare.

Endoscopy_UCTN_Code_CPL_1AJ_2AC Endoscopy_UCTN_Code_TTT_1AO_2AG

K. Fu1,2, T. Ishikawa2, T. Yamamoto2, Y. Kaji1 1 Department of Radiology, Dokkyo Medical University, Tochigi, Japan 2 Department of Diagnostic Imaging, Division of Endoscopy, Tochigi Cancer Center Hospital, Tochigi, Japan

References 1 Sano Y, Machida H, Fu KI et al. Endoscopic mucosal resection and submucosal dissec- tion method for large colorectal tumors. Dig Endosc 2004; 16: S88– S91 A 78-year-old man underwent total colo- treatment, including withholding oral in- 2 Fujishiro M, Yahagi N, Nakamura M et al. En- noscopy because of positive fecal occult take, intravenous administration of anti- doscopic submucosal dissection for rectal blood test. Two lateral spreading tumors biotics, and hyperalimentation. epithelial neoplasia. Endoscopy 2006; 38: (LST), approximately 35 mm and 40 mm In order to completely remove large colo- 493– 497 3 Yakobi-Shvili R, Cheng D. Tension pneumo- in size, were detected in the cecum and rectal tumors endoscopically en bloc, a peritoneum – a complication of colonosco- transverse colon, respectively. Both le- novel technique of ESD instead of conven- py: recognition and treatment in the emer- sions were endoscopically diagnosed as tional endoscopic mucosal resection gency department. J Emerg Med 2002; 22: adenoma or focal cancer in adenoma, (EMR) has been developed [1]. This tech- 419 – 420 4 Peppriell JE, Bacon DR. Acute abdominal and therefore considered good candi- nique is reportedly associated with a sig- compartment syndrome with pulseless dates for endoscopic resection. nificant incidence of complications, such electrical activity during colonoscopy with Initially, endoscopic submucosal dissec- as perforation and bleeding, in compari- conscious sedation. J Clin Anesth 2000; 12: tion (ESD) was attempted for en bloc re- son with conventional EMR [1,2]. How- 216 – 219 section of the LST located in the cecum. ever, most perforations that occur during During the procedure, although no defi- ESD are small and can be managed con- Bibliography nite perforation was recognized, the pa- servatively with endoclip placement if re- DOI 10.1055/s-2007-966489 tient became aware of marked abdominal cognized immediately. In the present Endoscopy 2009; 41: E245 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Georg Thieme Verlag KG Stuttgart · New York · distension, and then developed hypoten- case, the exact site of perforation, which ISSN 0013-726X sion, his blood pressure decreasing to may have been a mini-perforation, could 80 mm Hg. The procedure was immedi- not be detected endoscopically, and thus Corresponding author ately discontinued, and emergency ab- pressurized air resulted in increased in- K. Fu, MD dominal computed tomography (CT) tra-abdominal pressure. In general, in- Department of Radiology demonstrated a large pneumoperito- creased intra-abdominal pressure can Dokkyo Medical University neum with collapse of the inferior vena have numerous adverse physiologic ef- 880 Kitakobaysashi cava (l" Fig. 1). Paracentesis was per- fects, which may include decreased ve- Mibu formed for decompression with a 20 nous return, decreased cardiac output, Shimotuga Tochigi 321-0293 gauge puncture needle. The patient’s and altered ventilation-perfusion rela- Japan symptoms were relieved, and the blood tionships [3,4]. Tension pneumoperito- Fax: +81-282-865678 pressure and diameter of the inferior neum should be suspected in all patients [email protected] vena cava returned to normal immediate- who develop circulatory and/or respira- ly after decompression. The patient re- tory collapse with acute abdominal dis- covered uneventfully after conservative tension during or after endoscopy, espe-

Fu K et al. Tension pneumoperitoneum related to endoscopic submucosal dissection… Endoscopy 2009; 41: E245