Keywords
conservative - endoscopy - OVESCO
Case Discussion
An 80-year-old hypertensive woman, presented with biliary pain of 1-month duration.
Patient had elevated alkaline phosphatase with normal bilirubin, and ultrasound abdomen
showed cholelithiasis with dilated common bile duct and multiple stones with acoustic
shadowing within the bile duct. The patient was planned for elective endoscopic retrograde
cholangiopancreatography (ERCP); however, during the side viewing endoscopy perforation
of the duodenum occurred at D1-D2 junction, which was immediately recognized and further
procedure was stopped with plan for endoscopic closure of the defect.
Double-channel therapeutic scope (GIF-2TH 180, Olympus, Japan) with mounted OTSC clip
(size 12/6t, OVESCO Endoscopy AG, Tuebingen, Germany) was inserted under CO2 insufflation. The perforation site was identified at D1-D2 junction, which was approximately
2.5 cm to 2.8 cm in size (as scope with the mounted OVESCO clip could be easily negotiated
across the perforation site)[Fig. 1.] Initially, an attempt was made to close the defect using suction; however, due to
the large size of the perforation, lateral margins were not coming within the OVESCO
cap. During the procedure, we used different accessories to approximate the edges
of the defect[Fig. 2.]. Initially, the edges were tried to approximate with OTSC twin grasper (OVESCO Endoscopy
AG, Tuebingen, Germany) but due to friable margins, multiple attempts to approximate
the lateral edges was failed.[Fig. 2.] After that, we used the FTRD grasper (OVESCO Endoscopy AG) from one channel along
with twin grasper from another channel. However, due to wide and friable margins,
we could not approximate both the edges. Finally, we used two OTSC Anchor (OVESCO
Endoscopy AG) and applied over the healthy mucosa of two opposite ends of the defect
and pulled back both the anchors, which bought both margins of the defect within the
cap. Once we had secured final position, we applied the OVESCO clip. Immediately,
post-procedure, the entire defect was completely closed. The patient was kept on nil
per oral and started on intravenous antibiotics along with other supportive treatment.
She underwent CT abdomen with oral contrast, which was suggestive of no contrast leak
with clip in situ. The patient was started on an oral diet after 24 hours and discharged
after 72 hours of hospitalization. The patient underwent ERCP after 2 weeks of the
perforation, and complete biliary clearance was achieved ([Video 1]).
Video 1
Video describing the successful closure of large duodenal perforation by OVESCO with
the help of adjunct accessories
Discussion
With advancement of OTSC clips, the majority of iatrogenic perforations can be managed
endoscopically with high technical and clinical success rates. The efficacy of OTSC
is attributable to the ability of the clip to provide full-thickness closure of the
perforation. Moreover, it has higher compression force and captures a larger tissue
volume. Surgery is usually being preserved for cases with frank peritonitis, hemodynamic
instability, patients in whom an initial diagnosis of perforation was missed. Though
OTSC clips are associated with high technical and clinical success rates, the presence
of large perforation (>20–25 mm) poses a unique clinical challenge.[1] In such scenario, endoscopist can use various techniques for endoscopic closure
of such defects. Large (14/6) OVESCO clips mounted on colonoscope can be used for
such large defects; however, negotiating it across the upper esophageal sphincter
or duodenal sweep could be difficult.[2] Loop and clip method have also been attempted, but difficult position in the D1-D2
junction and not been able to provide full-thickness closure poses a major limitation.[3] In such a scenario, adjuvant accessories such as twin grasper or tissue anchor are
of great help as these accessories can grasp both the edges of the defect. Availability
and right knowledge of its use are very necessary for better outcomes. To conclude,
endoscopic closure of a large duodenal defect is feasible with the right use of accessories.
Fig. 1 (A) Large duodenal perforation at the D1-D2 junction (approximate size: 2.5 – 2.8 cm).
(B) Double-channel therapeutic scope (GIF-2TH 180, Olympus, Japan) with a mounted OVESCO
cap could be easily negotiated across the perforation site.
Fig. 2 (A) OTSC twin grasper has two jaws that can be opened separately at 90 degrees separately.
It helps in grasping both the edges of the lesion and bringing them in the OVESCO
cap. (B) The OTSC anchor allows precise alignment between the target tissue and the applicator
cap. It allows better approximation of the tissue, especially when indurated. It has
a diameter of 12 mm and the needle penetrate up to 4 mm. (C) The FTRD grasper is specifically designed for grasping the submucosal lesion for
full-thickness resection.
