S2328 A Tale of Two Perfs: Successful Repair of Dual Iatrogenic Duodenal Perforations Through Endoscopic Stenting

Abstract

INTRODUCTION: Duodenal perforations are rare but serious gastrointestinal injuries, which pose challenging management decisions dependent on their etiology.[1,2] We report the use of a fully-covered self-expanding metal stent (FC-SEMS) for the management of iatrogenic duodenal perforations, which resulted in successful healing of perforations albeit associated with delayed morbidity from stent migration. CASE DESCRIPTION/METHODS: A 33 year-old male was admitted following a major motor vehicle collision with severe intraabdominal injuries requiring multiple surgeries, leading to the development of intra-abdominal infection requiring percutaneous drainage of RUQ and midabdominal fluid collections. Eight weeks after drain placement, enteral feeds were initiated with upper GI series confirming an active duodenal leak (Figure 1A). Endoscopic intervention was pursued due to high operative risk and demonstrated evidence of lateral and medial duodenal perforations secondary to erosions from the percutaneous RUQ drain (Figures 2A and 2B). The duodenal perforations were successfully stented using a FC-SEMS (18 mm × 12 cm) and sutured in place with an over-the-scope suturing system (Figures 1B and 1C). Enteral feeds were reinitiated with a small but stable leak, and the patient was discharged 12 weeks later. Eight weeks after discharge, the patient was readmitted for soft tissue infection from a colocutaneous fistula from prior bowel surgery, however CT scan also showed stent migration into the jejunum (Figure 3A) with a stable duodenal leak. Single balloon enteroscopy was performed with removal of the stent facilitated by pulling the stent into the cap with rat tooth forceps and using the splinting tube as an overtube to minimize bowel injury during withdrawal. Final endoscopic visualization revealed complete healing of the peritoneal fistula and near-complete healing of the retroperitoneal fistula (Figures 2C and 2D). DISCUSSION: The use of SEMS for the management of duodenal perforations has previously been reported, although predominately in the treatment of malignant gastric outlet obstruction or biliary stent complications and with limited patient follow up data.[3–6] Our case illustrates the successful use of a FC-SEMS for healing of dual duodenal perforations in a patient whose level of illness precluded medical or surgical management. Our case also highlights the risk of stent related complications such as delayed stent migration which can be difficult to manage, in particular outside centers of expertise.Figure 1.: Figure 3A: Upper GI series showing medical (circle) and lateral contrast leakage (arrow) Figure 1B: Duodenal stent in place with contrast injection showing minimal leak Figure 1C: Stent sutured in place in the gastric antrum.Figure 2.: Figure 2A: Pigtail drain in duodenum (*) and peritoneal fistula (^) Figure 2B: Visible retroperitoneal drain (*) in retroperitoneal fistula after RUQ drain repositioned Figure 2C: Duodenal lumen 20 weeks following stent placement without evidence of peritoneal fistula Figure 2D: Healing retroperitoneal fistula, approximately 1-2 mm in diameter.Figure 3.: Figure 3A: Stent migration into the jejunum, 20 weeks after placement Figure 3B: Endoscopic view of jejunal stent including endoscopic sutures (*) Figure 3C: Stent following removal.