Continuation of common bile duct clearance with gallbladder stenting after duodenal perforation with subsequent treatment for tension pneumoperitoneum and pneumothorax.

Abstract

An 88-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) because of septic cholangitis with acute calculous cholecystitis. Unfortunately, incidental duodenal perforation (Stapfer classification type 1) [1] occurred during duodenoscope intubation by our trainee endoscopist. Gastroscopy with a transparent cap revealed a linear 4-cm defect with active oozing at the duodenal apex ([Video 1]). Perforation closure was attempted with preceding guidewire insertion into the downstream duodenal lumen ([Fig. 1]) to prevent accidental luminal closure [2]. The first traumatic type over-the-scope clip (OTSC, 12/6t; Ovesco) was deployed by suction on the lacerating tissue at the caudal side of the defect ([Fig. 2]). However, the defect did not close completely; therefore, a second OTS clip was deployed using twin graspers to appose the edges of the defect. Contrast enterography revealed no intraperitoneal leakage ([Fig. 3]). Immediately after closure, ERCP with stones removal and transpapillary gallbladder stenting with a double-pigtail plastic stent to prevent recurrent cholecystitis was successfully performed. At almost 40 minutes before completion of the procedure, the patient developed marked abdominal distension, hypotension, and desaturation. Tension pneumoperitoneum with right pneumothorax was confirmed by fluoroscopy ([Fig. 4]). Emergency needle decompression was performed using an 18 G needle to release the tension pneumoperitoneum, and the patient was then intubated. Her abdomen gradually softened with an improvement in oxygen saturation. At 4 hours later, plain radiography showed no free air ([Fig. 5]). The patient was extubated and resumed oral intake the following day.