Successful treatment of dehiscence after surgery for perforation of a large duodenal ulcer using endoscopy combined with regular clips and nylons

Abstract

A 56-year-old man was hospitalized for treatment of severe acute abdominal pain. Chest X-ray and abdominal CT showed the presence of free air intra-abdominally. A clinical diagnosis of acute generalized peritonitis due to gastro-duodenal perforation was made and emergency surgery was performed. At the time of surgery, a 3 cm-diameter perforation was identified on the anterior wall of the duodenal bulb, and treatment effected by omental patch. On the 12th day post-operatively, endoscopy confirmed that no leakage was present at the previously-perforated site in the duodenum. On day 17, food debris appeared unexpectedly at the surgical site due to wound dehiscence. Abdominal enhanced CT showed the presence of free air from the front of the duodenal bulb extending through the intra-abdominal space to the skin wound. Whilst fasting combined with a course of antibiotics, treatment for the site of leakage was performed. Using regular clips and nylon yarns under endoscopy, the hole was reefed and leakage of contrast medium significantly abated. Subsequently inflammation reduced dramatically. The patient’s condition discernibly improved and finally resolved without the need for invasive surgery.