Prospective evaluation of tension-reducing closure with intentional muscle-layer grasping for large colorectal post-ESD defects using an anchor-pronged clip (MANTIS study).

Triage suspected perforation with immediate IV access (2 large-bore IVs) and assessment of perfusion in parallel with diagnostics; obtain upright CXR and CT abdomen/pelvis (most sensitive/specific) plus labs and lactate, and start empiric broad-spectrum antibiotics. Fluid therapy is stratified by perfusion status, not given as a fixed protocol for all comers: in adults with sepsis-induced hypoperfusion or septic shock, give at least 30 mL/kg IV crystalloid within the first 3 hours (Surviving Sepsis Campaign 2026; conditional recommendation, low-certainty evidence), selecting the initial volume by individual patient characteristics and context (use adjusted or ideal body weight if BMI >30 kg/m²) with frequent, ongoing reassessment to avoid under- or over-resuscitation, alongside sepsis care: blood cultures as soon as possible and ideally before antimicrobials, lactate with serial measurement to guide resuscitation, and vasopressors if hypotension persists despite fluids. In patients without sepsis-induced hypoperfusion or shock, do not give protocolized volume resuscitation; use maintenance fluids or small individualized boluses guided by hemodynamic reassessment, and in fluid-sensitive patients (e.g., heart failure, end-stage renal disease) use smaller individualized boluses with close reassessment rather than a fixed weight-based volume. Obtain mandatory emergency surgical consultation for any confirmed perforation, hard peritoneal signs, free air, or hemodynamic instability, proceeding to exploratory laparotomy/laparoscopy or cause-specific surgery (Graham patch, Hartmann, colectomy). Selected contained post-procedural perforations that are small, clip-amenable, and hemodynamically stable may be managed conservatively with ICU monitoring, NPO, antibiotics, and serial imaging.