Endoscopic Closure of Iatrogenic Duodenal Perforation Using Dual Over-The-Scope (OTSC) Clips

Abstract

FigureIntroduction: Perforation of the duodenum is a rare complication of upper gastrointestinal endoscopy and is associated with significant morbidity and mortality. We present the technique of using over-thescope clips (OTSC) for successful closure of duodenal perforation. Methods: A 44 year old female was referred for endoscopic retrograde cholangiography (ERC) after an intraoperative cholangiogram done during laparoscopic cholecystectomy revealed common bile duct stones. A 1.5 cm full thickness perforation was found in the anterior wall of the second portion of the duodenum immediately after duodenoscope insertion. The ERC was aborted. An over-the-scopeclip (OTSC) 12/6 gc was attached to the therapeutic upper endoscope and endoscopy was performed. A twin grasper was passed through the channel of the endoscope to oppose the edges of the duodenal wall defect and pull it into the OTSC cap. One OTSC was applied to the site of the defect. A small residual defect was visible after placement of first OTSC. A second OTSC was placed adjacent to the first clip at the site of residual defect using suction technique with complete closure of the defect.Figure 1Figure 2Results: Abdominal CT scan with oral contrast done after endoscopic perforation closure showed free intraperitoneal and retroperitoeal air, but no leakage of enteric contrast was seen. The patient was kept NPO, a nasogastric tube was placed for gastric decompression and IV antibiotics were started. The patient's vital signs were stable and no evidence of peritonitis was found on serial clinical exams. MRI with oral contrast done at Day 3 showed a 5.7 x 3.2 cm collection with an air fluid level adjacent to the site of OTSC clips, but no leak of oral contrast was seen. The patient was therefore started on clear liquid diet and monitored clinically. She remained asymptomatic and tolerated clear diet well which was gradually advanced. An upper GI series with gastrograffin was done at Day 9 and showed no contrast leak. Two OTSC clips were seen on KUB x-ray. A follow up MRI/MRCP was performed at Day 45, which showed resolution of air fluid collection, no leak of oral contrast and resolution of biliary filling defects likely due to spontaneous passage of stones. Conclusion: Our case highlights successful endoscopic closure of duodenal perforation using dual OTSC clips placed tandemly when one clip is inadequate. The technical difficulties in application of OTSC can be circumvented by use of twin grasper and application of additional OTSC if needed.Figure 1