S2786 Iatrogenic Duodenal Perforation Repaired With a Lumen Apposing Metal Stent

Abstract

INTRODUCTION: Iatrogenic endoscopic perforations have a high mortality rate which is directly proportional to time of diagnosis and management. Until now, using clips have been commonly used in perforation repair and stents have been limited to a small subset of cases. We present the first reported case of LAMS being been used off-label for duodenal perforation. CASE DESCRIPTION/METHODS: 66 yo female with an unremarkable PMH presented with chronic epigastric pain and dysphagia. It was sharp, constant, radiated to the back, no relieving factors, worse with eating and associated with nausea, vomiting and diarrhea. CT abdomen revealed numerous enlarged mesenteric lymph nodes. An diagnostic EGD with EUS was performed and during the procedure a deep mucosal defect was noted in the posterior wall of the duodenal bulb, so a lumen apposing Axios stent was placed. Gastrograffin study confirmed the defect wasn’t a complete transmucosal tear; however repeat CT revealed pneumoperitoneum. She improved with supportive care and was discharged home. One month later a repeat EGD was performed to remove the stent and it was noted that the mucosal wall had healed completely. DISCUSSION: Perforation of the stomach and duodenum can be caused by both iatrogenic and non-iatrogenic trauma. With the widespread use of EGD, the incidence of iatrogenic perforation rises. Esophageal perforations are more common, however duodenal perforations have the highest morbidity and mortality rates. One study showed only 0.01% of EGD-related perforations involving the duodenum. It also reflected a 17% overall mortality with half involving the duodenum. Early identification and management is paramount to survival. One study where perforation was immediately identified and managed reported a 94.4% success rate. Another similar study proved mortality dramatically increased with delaying surgical management (>24 h). In our case the scope position was too unstable to place clips or sutures so a LAMS was deployed, thereby avoiding surgery and delay of care. Endoscopically-placed stents are alternatives to clipping, however they're primarily used in duodenal ulcer perforations. These current techniques are less frequently used due to their size, risk of stent migration, and complexity of deployment. LAMS wasn’t originally created for duodenal perforation, but its larger size and unique shape make it an ideal candidate. In cases where clipping isn't appropriate, stenting may be a better choice when compared to surgical intervention and delaying therapy.Figure 1.: No leak of oral contrast from the duodenum status post LAMS (yellow arrow). Small volume pneumoperitoneum in the upper abdomen (red arrows).Figure 2.: Red arrow pointing toward LAMS in duodenum without leak of oral contrast.Figure 3.: Follow-up EGD showing stable LAMS.