AIM: To identify the actual clinical management and associated factors of delayed perforation after gastric endoscopic submucosal dissection(ESD).METHODS: A total of 4943 early gastric cancer(EGC) patients underwent ESD at our hospital between January 1999 and June 2012. We retrospectively assessed the actual management of delayed perforation. In addition, to determine the factors associated with delayed perforation, after excluding 123 EGC patients with perforations that occurred during the ESD procedure, we analyzed the following clinicopathological factors among the remaining 4820 EGC patients by comparing the ESD cases with delayed perforation and the ESD cases without perforation: age, sex, chronological periods, clinical indications for ESD, status of the stomach, location, gastric circumference, tumor size, invasion depth, presence/absence of ulceration, histological type, type of resection, and procedure time.RESULTS: Delayed perforation occurred in 7(0.1%) cases. The median time until the occurrence of delayed perforation was 11 h(range, 6-172 h). Three(43%) of the 7 cases required emergency surgery, while four were conservatively managed without surgical intervention. Among the 4 cases with conservative management, 2 were successfully managed endoscopically using the endoloop-endoclip technique. The median hospital stay was 18 d(range, 15-45 d). There were no delayed perforation-related deaths. Based on a multivariate analysis, gastric tube cases(OR = 11.0; 95%CI: 1.7-73.3; P = 0.013) were significantly associated with delayed perforation.CONCLUSION: Endoscopists must be aware of not only the identified factors associated with delayed perforation, but also how to treat this complicationeffectively and promptly. AIM: To identify the actual clinical management and associated factors of delayed perforation after gastric endoscopic submucosal dissection (ESD).METHODS: A total of 4943 early gastric cancer (EGC) patients underwent ESD at our hospital between January 1999 and June 2012. We retrospectively After the assessment of actual management of delayed perforation. In addition, to determine the factors associated with delayed perforation, after excluding 123 EGC patients with perforations that generated during the ESD procedure, we analyzed the following clinicopathological factors among the remaining 4820 EGC patients by comparing the ESD Cases with delayed perforation and the ESD cases without perforation: age, sex, chronological periods, clinical indications for ESD, status of the stomach, location, gastric circumference, tumor size, invasion depth, presence/absence of ulceration, histological type, type of Resection, and procedure time.RESULTS: Delayed perforation occurred in 7(0.1%) cases. Me until the occurrence of delayed perforation was 11 h(range, 6-172 h). Three(43%) of the 7 cases required emergency surgery, while four was conservatively managed without surgical intervention. Among the 4 cases with conservative management, 2 Were successfully managed endoscopically using the endoloop-endoclip technique. The median hospital stay was 18 d(range, 15-45 d). There was no delayed perforation-related deaths. Based on a multivariate analysis, gastric tube cases (OR = 11.0; 95%CI: 1.7-73.3; P = 0.013) were significantly associated with delayed perforation.CONCLUSION: Endoscopists must be aware of not only the identified factors associated with delayed perforation, but also how to treat this complicationeffectively and promptly.