SUCCESSFUL ENDOSCOPIC MANAGEMENT OF DUODENAL PERFORATION THAT OCCURRED DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Abstract

The incidence of complications related to endoscopic retrograde cholangiopancreatography (ERCP) is relatively high compared with that related to other endoscopic procedures and the complications can worsen the patientʼs condition. In particular, duodenal perforation (DP) is life-threatening and usually requires emergency surgical interventions. Here, we demonstrate a successfully treated case of spontaneous DP during ERCP under endoscopic closure using the clipping technique. A 78-year-old woman was diagnosed with acute obstructive cholangitis due to choledocholithiasis. ERCP followed by endoscopic sphincterotomy (EST) and balloon choledocholithotomy was performed and succeeded in stone removal. However, while stretching the scope, the inferior duodenal angulus was injured with the scope head. Fat tissues, which seemed to be retroperitoneal fat, were observed through the injured mucosa, suggesting that ERCP-related DP occurred. The patient developed no symptoms and her general condition was stable. Although the hole was as large as 15 mm, no gas was detected in the intra-abdominal cavity under fluoroscopy. We tried to close the mucosal defect under endoscopy using the clipping technique. A total of seven clips were applied on the defect from both edges, shrinking the hole clip by clip. After complete mucosal closure, contrast enhance reagent was applied and only a small amount was retained in the retroperitoneal cavity. Intensive follow-up with antibiotic therapy was continued and her clinical course was uneventful. Although the indication for endoscopic closure of DP depends on the patientʼs condition, technical skill of the endoscopist and backup of surgeons, this endoscopic procedure is less invasive than surgical intervention and worth considering. We report our case with a literature review.