Endoscopic Closure of Gastric Perforation From Eroded JP Drain Using Over-the-Scope Clip (OTSC)

Abstract

Jackson-Pratt (JP) drains are commonly used to prevent fluid accumulation and to reduce the risk of infection after surgical procedures. Complications related to JP drains are rare but include infection, bleeding, drain obstruction, dislodgement, and small bowel injury. Herein, we present a rare case of JP drain eroding into the stomach following gastrojejunostomy and successful endoscopic closure of the full thickness perforation with over-the-scope-clips (OTSCs). A 55-year-old female with multiple comorbidities and past surgical history of gastric bypass performed 1-year prior presented with diffuse abdominal pain. Computed Tomography scan revealed a ventral hernia with several non-inflamed small bowel loops and pneumoperitoneum with unclear perforation site. Exploratory laparotomy showed a 1 cm perforation at the gastrojejunostomy (GJ) site and an incarcerated incisional hernia with omentum. Resection of the gastrojejunostomy anastamosis, along with creation of a new gastrojejunostomy anastomosis and repair of incision hernia was performed. The hospital course was complicated with sepsis, leakage from the GJ anastamosis and right paracolic gutter which was drained. Patient subsequently developed abdominal pain and leucocytosis. A leak was again noted at the GJ anastomosis. On esophagogastroduodenoscopy (EGD) a JP drain was noted in a large defect in the stomach adjacent to the anastomatic site and surgical clips [Figure 1]. The JP drain was withdrawn until it was no longer seen in the stomach [Figure 2] and the defect successfully approximated with an OTSC and 2 hemoclips [Figures 3, 4]. Subsequent upper GI series showed no leakage. Gastric perforation caused by a JP drain is a rare complication. Due to its rarity, its incidence is largely unknown. Stiff or non-flexible drains, faulty staple/suture lines, long term placement, and edema at the surgical site increase the risk for perforation. Added precaution should be taken where stomach anatomy has been surgically modified. Our case also highlights the effective and safe use of OTSCs in successful closure of iatrogenic gastric perforation.Figure: JP drain in the stomach.Figure: Large defect left in the stomach after JP drain was pulled.Figure: Defect closed with OTSC and hemoclips applied adjacent to OTSC.