Keywords
endoscopic retrograde cholangiopancreatography - over-the-scope clip - perforation
Introduction
Duodenal perforation is a serious complication, which can occur during endoscopic
retrograde cholangiopancreatography (ERCP) and is reported in 0.14 to 0.61% of all
ERCP procedures.[1]
[2]
[3]
[4]
[5] According to the classification given by Stapfer et al, ERCP perforations can be
divided into four subgroups.[6] Type I injuries correspond to lateral or medial duodenal wall perforations and mostly
occur due to injury due to duodenoscope; type II injuries are perivaterian and most
commonly occur during sphincterotomy or sphincteroplasty; type III injuries are biliary
or pancreatic duct injuries due to guidewire, cannula, or basket; and type IV injuries
are the presence of retroperitoneal air alone. Type IV injuries do not require any
treatment. While type II and III injuries respond better to nonoperative treatment,
type I injuries were conventionally being treated with surgery as they are large and
often lead to peritonitis. As most of the elderly patients undergoing ERCP have underlying
comorbidities, emergency surgery for management of such perforations is challenging.
With advances in therapeutic endoscopy, interest in endoscopic management of post-ERCP
perforation has increased. Various endoscopic devices such as through-the-scope clips,
ligation bands,[7]
[8] fibrin glue, endoclips and endoloops,[9] suturing devices, and covered luminal stents have been used for the closure of perforation.
Most of the existing endoscopic devices are designed for application in small perforations.
Closure may not be optimal in most cases, especially with inexperienced operators.
Over-the-scope clip (OTSC) device can close large perforations with the higher force
of compression and is now being increasingly used to manage duodenal perforations.[10]
[11] We report our experience with the endoscopic closure of type I duodenal injury with
OTSC in two patients.
Patients and Procedure
Both the ERCPs were performed at a high-volume tertiary care referral endoscopy center
performing >1500 ERCPs in a year.
Patient 1
A 79-year-old patient with the previous history of coronary artery disease, chronic
kidney disease, and hypertension presented with right upper quadrant pain of 10-day
duration. Clinical examination revealed tenderness in the right hypochondrium. Liver
biochemistry revealed total/direct bilirubin 1.14/0.31 mg/dL (normal 0.2–1.2/0–0.2
mg/dL), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) 31/15 U/L
(normal 17–59/21–72 U/L), and alkaline phosphatase (ALP)/gamma-glutamyl transpeptidase
(GGT) 63/15 U/L (normal 38–126/15–73 U/L). Total leukocyte count was 9.7 thousands/uL
(normal 4–11 thousands/uL), and serum creatinine was 2.7 mg/dL (normal 0.7–1.2 mg/dL).
Ultrasound abdomen revealed dilated intrahepatic biliary radicals with multiple common
bile duct (CBD) stones, and ERCP was planned.
ERCP was performed in the left lateral decubitus position under conscious sedation
with midazolam and pentazocine, and carbon dioxide gas was used for insufflation.
The procedure was performed with olympus duodenoscope (TJF-180V, Olympus Corporation,
Tokyo, Japan). Papillary orifice was normal, and CBD opening could be cannulated easily
with sphincterotome (Ultratome XL, 5 mm Short Nose, Boston scientific, Alajuela, Costarica)
and 0.032-inch Terumo guidewire (Radiofocus Guidewire M 0.032-inch, 260-cm, Fujinoma,
Japan). Sphincterotomy was done for three-fourths part of intramural part of CBD.
Cholangiogram revealed multiple filling defects, and stone extraction was done with
dormia basket (Grasping Forceps, 22-mm, Aomori, Japan). However, during final CBD
clearance with balloon sweep (Boston Scientific Extractor Pro XL, 15 mm, Cork, Ireland),
trauma occurred on the lateral duodenal wall. Perforation was immediately suspected
due to visualization of a defect in the duodenum and confirmed by the presence of
perinephric and subdiaphragmatic air on fluoroscopy. One 10 French × 10-cm straight
stent (Cotton-Leung Biliary stent CLSO, Cook Ireland, Limerick, Ireland) was placed
in CBD, and duodenoscope was withdrawn. Because of comorbid conditions and elderly
age group, surgery was not preferred. Option of closing the perforation with the endoscopic
device was discussed with family, and procedure was done with consent.
Endoscopy using a forward-viewing endoscope revealed 10-mm–sized defect in the lateral
duodenal wall ([Fig. 1]). Endoscope was loaded with the 12-mm OTSC (11-mm, 12/6t, OTSC system, Ovesco Endoscopy,
Tübingen, Germany) ([Fig. 2]). At the perforation site, suction was used to pull the margins inside the cuvette,
and clip was deployed ensuring approximation of all the margins ([Fig. 3]). Immediate contrast study did not reveal any leak into periduodenal space. A triple-lumen
nasojejunal tube (Freka Trelumina 150-cm, Fresenius Kabi, Bad Homburg, Germany) was
placed for gastric aspiration and jejunal feeding. The patient was started on IV fluids
and antibiotics. Jejunal feeds were started on the third day, and the patient had
subsequent uneventful course in the hospital. Computed tomography (CT) scan was done
on day 5, which revealed small amount of residual air without any periduodenal collection.
The nasojejunal tube was removed, and the patient was discharged two days after the
CT scan. The patient has been under follow-up for the past 6 months and is doing well.
Fig. 1 Perforation in the lateral duodenal wall (marked with arrow).
Fig. 2 Over-the-scope clip with rounded teeth loaded on over-the-scope clip applicator cap.
The applicator cap has to be mounted on the tip of the endoscope.
Fig. 3 Complete closure of the lateral duodenal wall perforation with over-the-scope clip.
Patient 2
An 84-year-old woman presented right upper quadrant pain for two days without any
history of fever. The patient had a history of stroke for which she was taking dabigatran
etexilate mesylate and had undergone laparoscopic cholecystectomy for gallbladder
stones previously. Examination revealed icterus and tenderness on deep palpation in
the right hypochondrium. Laboratory evaluation revealed increased total and direct
bilirubin 3.7 (normal 0.2–1.2 mg/dL) and 2.4 mg/dL (normal 0–0.2 mg/dL), respectively,
AST/ALT 165/150 IU/L (normal 17–59/21–72 U/L), ALP/GGT 164/268 IU/L (normal 38–126/15–73
U/L), and normal leukocyte count. Ultrasound abdomen showed dilated CBD with multiple
calculi (largest measuring 1.6 cm) with intrahepatic biliary radical dilatation. Oral
anticoagulant was withheld, and the patient was started on low-molecular-weight heparin
(enoxaparin 30 mg subcutaneously twice daily), which was withheld on the day of ERCP.
Similar complication occurred in this patient also lateral duodenal wall injury due
to duodenoscope was immediately identified and closed with 12-mm OTSC, and the patient
had uneventful further hospital stay, was discharged on day 7, and is under regular
follow-up for 4 months.
Discussion
Lateral duodenal perforation during ERCP is a serious complication. It occurs due
to direct trauma by duodenoscope. In our center, which performs around 1,500 ERCP
procedures a year, we encountered two such cases in the past 6 months.
Lateral duodenal perforations are diagnosed immediately due to direct visualization
of retroperitoneal tissue or visualization of air around the duodenum under fluoroscopy.
They are usually large and can lead to peritoneal contamination. Conventionally, these
patients were treated by surgical intervention. Surgical procedures included repair
with an omental patch, pyloric exclusion, and gastrojejunostomy.
Elderly patients with comorbidities poorly tolerate emergency surgical procedures.
Closure with minimally invasive techniques using endoscopic intervention is desirable
in these patients. Both of our patients were elderly and had comorbidities, and hence,
the endoscopic closure was considered for initial treatment. Endoscopic techniques
include through-the-scope clips, covered duodenal stents, band ligation with or without
clips, and purse-string closure. All these procedures have limitations. They are useful
mostly for closing small perforations, are time consuming, and mostly require special
endoscopes, such as double-channel endoscope. Fujishiro et al reported their experience
in managing perforations which occurred during endoscopic submucosal dissection in
27 patients. They concluded that perforations <1 cm and clean gastrointestinal contents
can be successfully closed with through-the-scope clips by an experienced endoscopist.[12]
Recently, OTSC has been increasingly used for the management of various complications
such as fistula, perforation, and gastrointestinal bleed. The efficacy of OTSC is
attributable to the ability of the clip to provide full-thickness closure of the perforation.
This has been demonstrated in several animal models.[13]
[14] OTSC is easier to apply, less time-consuming, has higher compression force, and
captures a larger tissue volume.[15]
[16] Haito-Chavez et al[17] reported the outcome of OTSC in 188 patients, of which 48 had perforations (9 patients
had duodenal perforations). They reported long-term success rates of 90%. OTSC was
more successful if used as primary modality of repair, rather than for rescue treatment.
OTSC has been used previously for duodenal perforation,[10]
[11] occurring during ERCP. Donatelli et al reported the use of combined colonic and
gastric OTSC for the closure of large duodenal perforations.[10] Buffoli et al reported the use of OTSC for the closure of jejunal perforation occurring
during ERCP in a patient with altered anatomy.[11] Suction or twin graspers have been used with OTSC to approximate the margins. Because
we applied the clip immediately after perforation, the margins were soft and nonfibrotic,
and approximation with suction was successful. In our both patients, primary closure
of perforation could be achieved without any long-term complications.
In summary, OTSC is an effective modality in patients with lateral duodenal wall perforation
and should be considered, especially in patients with comorbid conditions.
Financial Support and Sponsorship
Nil.
