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DOI: 10.1055/s-0042-103926
Iatrogenic duodenal perforation during underwater ampullectomy: endoscopic repair using polyglycolic acid sheets
Publication History
Publication Date:
14 March 2016 (online)
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Endoscopic resection is used to treat duodenal lesions [1]. However, the rate of perforation in the duodenum is relatively higher than that in other areas, and such perforation can be fatal [2]. Polyglycolic acid (PGA) sheets can be used to prevent delayed perforation after endoscopic submucosal dissection (ESD) in the duodenum [3], and to cover a delayed perforation after gastric ESD [4]. However, no reports have described the usefulness of PGA sheets for treating immediate iatrogenic duodenal perforation during underwater ampullectomy.
A 45-year-old woman had a whitish, flat, laterally spreading 30-mm adenoma involving the ampulla of Vater ([Fig. 1]). We decided to remove the lesion using underwater ampullectomy with a side-viewing duodenoscope [5]. We filled the duodenum with 0.9 % saline to avoid hyponatremia, a major complication of the underwater technique, and performed piecemeal resection with an electrosurgical snare (SnareMaster, SD-210U-25, 25 mm; Olympus, Tokyo, Japan) ([Fig. 2]). During the piecemeal resection, after removal of three tissue specimens, an approximately 10-mm perforation was observed on the posterior wall of the ampulla ([Fig. 3]). After completion of the piecemeal resection, we filled the perforation with PGA sheets (Neoveil; Gunze Co., Kyoto, Japan), cut to approximately 20 × 10 mm, and then sprayed fibrin glue over the site (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) ([Fig. 4]). We then placed nasoduodenal and nasobiliary drainage tubes and a pancreatic duct stent. Computed tomography showed no free air or ascites in the peritoneal cavity, but a small amount of gas was present along the retroperitoneum ([Fig. 5]). On postoperative day (POD) 1, the patient complained of only mild abdominal and back pain without fever, and the pain disappeared the next day. Esophagogastroduodenoscopy on POD 4 showed that the PGA sheets completely covered the perforation site ([Fig. 6]). The patient was discharged on POD 15.
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PGA sheets may be useful for treating immediate iatrogenic duodenal perforation and for preventing delayed perforation.
Endoscopy_UCTN_Code_CPL_1AK_2AC
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References
- 1 Hirasawa R, Iishi H, Tatsuta M et al. Clinicopathologic features and endoscopic resection of duodenal adenocarcinomas and adenomas with the submucosal saline injection technique. Gastrointest Endosc 1997; 46: 507-513
- 2 Inoue T, Uedo N, Yamashina T et al. Delayed perforation: a hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig Endosc 2014; 26: 220-227
- 3 Takimoto K, Toyonaga T, Matsuyama K. Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms. Endoscopy 2012; 44: E414-E415
- 4 Ono H, Takizawa K, Kakushima N et al. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015; 47: E18-E19
- 5 Granata A, Curcio G, Ligresti D et al. Endoscopic ampullectomy: to inject or not to inject? The underwater technique. Endoscopy 2014; 46: E478-E479