Acute cholangitis after over-the-scope clip placement involving the duodenal papilla that was rescued by antegrade stenting via the percutaneous transhepatic biliary drainage route

The over-the-scope (OTS) clip (Ovesco Endoscopy, Tübingen, Germany) has been developed and is widely used for the treatment of gastrointestinal perforations and fistulas [1]. However, when the perforation or fistula is located near the duodenal papilla, the use of OTS clips poses a potential risk of acute obstructive cholangitis or pancreatitis from involvement of the papilla [2]. Herein, we report a case of acute cholangitis after OTS clip placement involving the duodenal papilla, which was rescued by antegrade stenting via the percutaneous transhepatic biliary drainage (PTBD) route.

A 72-year-old woman was transferred from another hospital for the treatment of walled-off pancreatic necrosis (WON) after post-endoscopic retrograde cholangiopancreatography pancreatitis ([Fig. 1]), and percutaneous drainage was performed. Contrast injected via the percutaneous tube 12 days after the procedure revealed a fistula between the WON and the duodenum ([Fig. 2]). Because the infected WON was well controlled, closure of the endoscopic fistula was performed with two OTS clips ([Video 1]). The day following the procedure, the patient developed abdominal pain and fever, and a computed tomography scan showed bile duct obstruction due to the OTS clip. Endoscopy revealed that the duodenal papilla had been caught in the clip, and PTBD was performed ([Fig. 3]). Antegrade stenting via the PTBD route was successfully achieved 14 days later ([Fig. 4]). Subsequently, after repeated biliary stent replacement, the OTS clips spontaneously dislodged. The patient has remained symptom-free after stent removal.

Fig. 1 Contrast-enhanced computed tomography image showing a large area of walled-off pancreatic necrosis.

Fig. 2 Radiographic image following injection of contrast via the percutaneous tube showing a fistula (arrow head) between the walled-off pancreatic necrosis and the duodenum.

Video 1 Video showing closure of the fistula by over-the-scope clip placement and subsequent successful antegrade stenting via the percutaneous transhepatic biliary drainage route for acute cholangitis caused by the clip placement involving the duodenal papilla.

Fig. 3 Endoscopic views: a before performing fistula closure; b after closure of the fistula with over-the-scope (OTS) clips showing the duodenal papilla (arrow) had been caught in the clip.

Fig. 4 Fluoroscopic view after antegrade stenting via the percutaneous transhepatic biliary drainage route had been successfully performed.

When closing a fistula of the duodenum, it is often difficult to secure a clear visual field owing to the narrow lumen and edematous mucosa surrounding the lesion. The findings from this case suggest that, when a fistula is located near the duodenal papilla, endoscopists should consider prophylactic measures, such as biliary and pancreatic stenting, or placement of a standard endoclip between the fistula and the duodenal papilla [3].

Endoscopy_UCTN_Code_CPL_1AK_2AI

• References

• 1 Manta R, Manno M, Bertani H. et al. Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: case series from a tertiary referral center. Endoscopy 2011; 43: 545-548
• 2 Alastal Y, Hammad TA, Nawras M. et al. Acute cholangitis following biliary obstruction after duodenal OTSC placement in a case of large chronic duodenocutaneous fistula. Case Rep Gastrointest Med 2015; 2015: 647806
• 3 Kanaya K, Toyonaga H, Hayashi T. et al. Endoscopic clipping to prevent papillary obstruction when closing a duodenal perforation with an over-the-scope clip. VideoGIE 2021; 6: 266-268