Actinomycosis associated with a permanently implanted duodenal over-the-scope clip

The over-the-scope (OTS) clip system is a safe and effective endoscopic therapy for gastrointestinal bleeding, perforation, and leakage [1] [2]. A recent review reported an overall complication rate of 1.7 % [1]. We report the case of a 76-year-old woman with a complication that arose 11 years after the placement of two OTS clips (Ovesco Endoscopy AG, Tübingen, Germany).

The patient had undergone resection by hybrid endoscopic submucosal dissection of a 25-mm duodenal adenoma 11 years previously. The procedure was technically difficult owing to fibrosis and was ultimately complicated by a microperforation, which was managed by the placement of two OTS clips. Histology revealed a tubulovillous adenoma with low grade dysplasia.

Follow-up esophagogastroduodenoscopies showed no signs of recurrence. Biopsy specimens of the scar revealed regenerative mucosa with hyperplastic changes. Both OTS clips stayed in place for 8 years, after which spontaneous dislodgement of one OTS clip occurred. Endoscopic examination then revealed a non-dysplastic mucosal bridge – double lumen appearance of the duodenum – with one clip still correctly placed.

Eventually 11 years after placement of the OTS clips, the mucosa surrounding the remaining clip had a villous aspect ([Fig. 1]); biopsies were taken, which were positive for Actinomyces ([Fig. 2]). A computed tomography scan was performed, which was negative for regional lymphadenopathy and regional spread. Following multidisciplinary discussion, a penicillin-based treatment was proposed and the OTS clip was successfully extracted. A decision was made not to cut the mucosal bridge, because the patient was asymptomatic. At 6-month follow-up, no signs of recurrence were present ([Video 1]).

Fig. 1 Endoscopic appearance of duodenal actinomycosis associated with an over-the-scope clip that had been in place for 11 years.

Fig. 2 Grocott staining showing the filamentous structures of Actinomyces.

Video 1 Diagnosis, treatment and follow-up of actinomycosis associated with a permanently implanted duodenal over-the-scope clip.

Abdominopelvic actinomycosis in immunocompetent people has been described [3]. In the literature, an association with foreign bodies has been reported, predominantly with intrauterine contraceptive devices [3]. To our knowledge, this is the first published case of actinomycosis occurring in relation to an OTS clip.

Endoscopy_UCTN_Code_CPL_1AH_2AC

• References

• 1 Kobara H, Mori H, Nishiyama N. et al. Over-the-scope clip system: A review of 1517 cases over 9 years. J Gastroenterol Hepatol 2019; 34: 22-30
• 2 Tashima T, Ohata K, Sakai E. et al. Efficacy of an over-the-scope clip for preventing adverse events after duodenal endoscopic submucosal dissection: a prospective interventional study. Endoscopy 2018; 50: 487-496
• 3 Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ 2011; 343: d6099