Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Abstract

Duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication, but it has a relatively high mortality risk. Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation. The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma. However, the current standard treatment for duodenal free wall perforation is surgical repair. Recently, several case reports of endoscopic closure techniques using endoclips, endoloops, or fully covered metal stents have been described. We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers. All the cases were simply managed by endoclips under transparent cap-assisted endoscopy. Based on the available evidence and our experience, endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations. Our results suggest that endoscopists may be more willing to use this treatment.

Figure 1

Endoscopic images of four cases demonstrating a large perforation on bulb and lateral wall of the second portion of duodenum, and successful primary endoscopic closure using multiple endoclips.

Figure 2

A simple abdomen X-ray shows both subphrenic pneumoperitoneum (A) and 6 d later, the follow-up upper gastrointestinal investigation (UGI) reveals no contrast leaks (B).

Figure 3

An abdominal computed tomography (CT) shows a severe pneumoretroperitoneum (A), and follow-up UGIs done 6 d later reveal no contrast leaks (B).

Figure 4

Initial abdominal CT following perforation shows pneumoperitoneum and subcutaneous emphysema (A), and follow up UGIs performed 8 d later reveal no contrast leaks (B).

Figure 5

Abdominal CT images showing a pneumoretroperitoneum, and subcutaneous emphysema following perforation (A) and a marked improvement 4 d after conservative management (B).