779 Endoscopic Repair of a Chronic Duodenal Perforation Complicated by a Contained Collection: A Case Report

Abstract

Abstract Duodenal perforations are a surgical emergency with high mortality. Most perforations require open or laparoscopic surgical repair, whereby the ulcer is oversewn, sometimes using a Graham patch. However, surgery is not without complications. We report the case of a 70-year-old man with a chronic, perforated duodenal ulcer that was repaired endoscopically. The patient presented with a 1-month history of epigastric abdominal pain, exacerbated by eating, and associated with a weight loss of 3.5 stones. Examination revealed a hard, irregular mass in the epigastrium. CT imaging showed a 6.8cm x 5.2cm x 4.1cm collection with an air-fluid level communicating with the D2 duodenum and extravasation of contrast into the collection. The collection was unable to be drained under radiological guidance due to difficulty in visualising and accessing it. Surgical intervention was deemed difficult to due to the site and chronicity of the perforation. The patient underwent endoscopic repair. Two interrupted sutures were placed using an Apollo overstitch system. APC was applied to the edges of the perforation and an OVESCO clip was placed ontop. Repeat CT imaging did not show any evidence of recurrent perforation. Endoscopic repairs have mainly been performed as an adjunct to surgical repair or during ERCP procedures, primarily using endoclips. We present a case where endoscopic repair alone was successful in sealing a duodenal perforation whilst leaving the collection intact. We believe this case is interesting and with advances in endoscopy, endoscopic repair could provide a minimal invasive option for managing duodenal perforations, especially complicated, chronic ones.