Successful endoscopic closure of iatrogenic duodenal perforation with the new Padlock Clip

Although duodenal perforations are rare [1], they represent one of the most critical complications of endoscopic ultrasound (EUS) and may be fatal in elderly patients. Following the introduction of endoscopic clips, stents, and over-the-scope systems into clinical practice, endoscopic management of perforations has became the first therapeutic option [2] [3].

We present the case of a 62-year-old man with jaundice, who was referred to the Digestive Endoscopy Unit of Humanitas Research Hospital (Rozzano, Italy) to undergo EUS-guided fine-needle aspiration of a solid lesion in the pancreatic head ([Fig. 1]). The EUS was performed using a linear echoendoscope (GF-UCT140; Olympus Optical Co., Tokyo, Japan), CO₂ insufflation, and with the patient under deep sedation with propofol.

Fig. 1 Solid lesion seen in the pancreatic head on endoscopic ultrasound.

During scope withdrawal through the duodenum, we observed a type-1 [4], full-thickness defect, of 13 mm in diameter, at the upper duodenal knee ([Fig. 2]). A stiff guidewire was placed in the duodenum to help expose the defect. A twin grasper (Ovesco Endoscopy AG, Tübingen, Germany) was used to approximate the mucosal edges of the perforation. Then, a gastroscope loaded with the new Padlock Clip (Aponos Medical Co., Kingston, New Hampshire, USA) ([Fig. 3]) was used to seal the defect ([Video 1]). Finally, a contrast radiograph confirmed the complete closure of the perforation ([Fig. 4], [Fig. 5]).

Fig. 2 Full-thickness defect at the upper duodenal knee.

Fig. 3 The new Padlock Clip (Aponos Medical Co., Kingston, New Hampshire, USA).

Video 1: Endoscopic closure of an iatrogenic duodenal perforation using the new Padlock Clip system (Aponos Medical Co., Kingston, New Hampshire, USA).

Fig. 4 Final endoscopic appearance after deployment of the Padlock Clip (Aponos Medical Co., Kingston, New Hampshire, USA).

Fig. 5 Final fluoroscopic appearance of the Padlock Clip (arrow; Aponos Medical Co., Kingston, New Hampshire, USA).

The Padlock Clip is a new over-the-scope system designed to be placed parallel to the endoscope, without occupying the operative working channel [5]. To our knowledge, this is the first clinical experience of closure of a duodenal iatrogenic perforation using the Padlock Clip.

Endoscopy_UCTN_Code_CPL_1AL_2AB

• References

• 1 Carrara S, Arcidiacono PG, Mezzi G. et al. Pancreatic endoscopic ultrasound-guided fine needle aspiration: complication rate and clinical course in a single centre. Dig Liv Dis 2010; 42: 520-523
• 2 Paspatis GA, Dumonceau JM, Barthet M. et al. Diagnosis and management of iatrogenic endoscopic perforations: position statement from the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2014; 46: 1-19
• 3 Guarner-Argente C, Córdova H, Martínez-Pallí G. et al. Yes, we can: reliable colonic closure with the Padlock-G clip in a survival porcine study (with video). Gastrointest Endosc 2010; 72: 841-844
• 4 Mangiavillano B, Caruso A, Manta R. et al. Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation: a multicenter retrospective study and a classification of gastrointestinal tract perforations. World J Gastrointest Surg 2016; 8: 315-320
• 5 Armellini E, Crinò SF, Orsello M. et al. Novel endoscopic over-the-scope clip system. World J Gastroenterol 2015; 21: 13587-13592