Successful Treatment of Duodenal Perforation with Over-The-Scope Clip after Failed Surgical Repair

Abstract

Purpose: Over-The-Scope Clips (OTSC®) have been reported to be useful in primary repair of iatrogenic endoscopic perforations. We report the successful use of the OTSC® in an elderly patient who failed surgical repair for an iatrogenic duodenal perforation. Methods: A 94-year-old man presented with a history of chronic duodenal strictures due to a duodenal ulcer. He was limited to a liquid diet and had undergone two prior balloon dilations without fluoroscopy. The third dilation, with fluoroscopic guidance, identified the stricture at the apex of the duodenal bulb. As the balloon was dilated to 12 mm, a small amount of blood was seen coming from the stricture. The patient felt well and was discharged. The following day, the patient presented with dyspnea and an episode of coffee-ground emesis. On exam, the patient was tachypneic with a grossly distended, hypertympanic, tender abdomen. Abdominal and pelvic CT revealed a peri-duodenal fluid collection in the anterior perirenal space consistent with a duodenal perforation. The patient was taken to the OR for exploration, where a fist-sized abscess containing coffee ground material as well as a 1.5-cm posterior perforation of the duodenum was found. The duodenum was closed with an omental patch; a gastrojejunostomy was formed and a feeding jejunostomy created. He recovered well until post-operative day six when he experienced bilious emesis and a leukocytosis of 21.1 x 109/L. A CT of the abdomen with oral contrast showed a persistent duodenal perforation. The patient was made NPO and kept on IV antibiotics. Two weeks after the initial repair, endoscopy was performed which identified an abnormal area which had a white non-mucosal base and sutures, representing the area of the failed repair. An OTSC was deployed and the opening could no longer be visualized. Results: The following day, an UGI study revealed no evidence of an extraluminal leak. Five days after clip placement, abdominal CT showed persistent right pararenal fluid collections without evidence of fluid extravasation. The collections were drained by radiology. The patient was discharged on a pureed diet to a skilled nursing facility a week later without further complications. Conclusion: Over-The-ScopeClips may be an intervention to avoid surgery or re-surgery for iatrogenic endoscopic perforations. Given this patient's advanced age, OTSC was attempted and was successful. To our knowledge, this is the first case report of its use after failure of surgical repair. Our unusual case suggests that OTSC should be considered an option in repair of iatrogenic perforation even after failed surgical repair.