Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent

Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for suspected choledo-cholithiasis, and a retroperitoneal duodenal perforation (sphincterotomy-related) occurred. Despite initial conservative management, the patient underwent a laparotomy and drainage of the retroperitoneal space. After that, a high volume duodenal fistula developed. Six weeks after the initial ERCP, the patient underwent a repeat endoscopy and placement of a CEMB stent with an indwelling nasobiliary drain. The fistula healed completely and the stent was removed two weeks later. We suggest the transient use of CEMB stents for the closure of sphincterotomy-related duodenal perforations. They can be placed either during the initial ERCP or even later if there is radiographic or clinical evidence that the leakage persists.

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session.There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later.Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

Duodenal perforation after organophosphorus poisoning: A case report

BACKGROUND Organophosphorus poisoning(OP)is one of the common critical conditions in emergency departments in China,which is usually caused by suicide by taking oral drugs.Patients with severe OP have disturbance of consciousness,respiratory failure,toxic shock,gastrointestinal dysfunction,and so on.As far as we know,the perforation of the duodenum caused by OP has not been reported yet.CASE SUMMARY A 33-year-old male patient suffered from acute severe OP,associated with abdominal pain.Multiple computed tomography scans of the upper abdomen showed no evidence of intestinal perforation.However,retrograde digital subtraction angiography,performed via an abdominal drainage tube,revealed duodenal perforation.After conservative treatment,the symptoms eased and the patient was discharged from hospital.CONCLUSION Clinicians should pay close attention to gastrointestinal dysfunction and abdominal signs in patients with severe OP.If clinical manifestation and vital signs cannot be explained by common complications,stress duodenal ulcer or perforation should be highly suspected.

An isolated duodenal perforation in pediatric blunt abdominal trauma:a rare but distinct possibility

Isolated duodenal perforation(IDP)in pediatric trauma is rarely reported.Since most of the children with blunt trauma are managed expectantly,timely diagnosis is imperative to avoid morbidity and mortality.We report a case of IDP and emphasize on certain specific clinical features indicating possibility of duodenal injury.We also stress upon the role of early contrast-enhanced computerized tomography(CECT)in such cases.

Balloon dilation of congenital perforated duodenal web in newborns: Evaluation of short and long-term results

BACKGROUND Incomplete congenital duodenal obstruction(ICDO)is caused by a congenitally perforated duodenal web(CPDW).Currently,only six cases of balloon dilatation of the PDW in newborns have been described.AIM To present our experience of balloon dilatation of a perforated duodenal memb-rane in newborns with ICDO.METHODS Five newborns who underwent balloon dilatation of the CPDW along a prein-stalled guidewire between 2021 and 2023 were included.Nineteen newborns diagnosed with ICDO who underwent laparotomy were included in the control group.RESULTS In all cases,good anatomical and clinical results were obtained.In three cases,a follow-up study was conducted after 1 year.The average time to start enteral feeding per os was significantly earlier in the study group(4.4 d)than in the laparotomic group(21.2 days;P<0.0001).The time spent by patients in the intensive care unit and hospital after balloon dilatation was also significantly shorter.We determined the selection criteria for possible and effective CPDW balloon dilatation in newborns as follows:(1)Presence of dynamic radiographic signs of the passage of a radiopaque substance beyond the zone of narrowing or radiographic signs of pneumatisation of the duodenum and small bowel distal to the web;(2)presence of endoscopic signs of CPDW;(3)successful cannulation with a guidewire performed parallel to the endoscope,with holes in the congenital duodenal web;and(4)successful positioning of the balloon performed along a freestanding guidewire on the web.CONCLUSION Strictly following selection criteria for newborns with ICDO caused by CPDW ensures that endoscopic balloon dilatation using a pre-installed guidewire is safe and effective and shows good 1-year follow-up results.

Retroperitoneal epithelioid sarcoma: A case report

Epithelioid sarcoma(ES), a mesenchymatous malign neoformation, is often diagnosed in later stages and associated with high recurrence index, metastasis and mortality. We report a case of a 65 years old male, with history of abdominal pain and upper gastrointestinal bleeding. Endoscopy demonstrated a posterior duodenal wall perforation communicating with a solid retroperitoneal neoformation. Endoscopic biopsy was performed, with a final report of ES. The patient was submitted for surgical palliation due to the tumor's unresectability. Retroperitoneal ES is an extremely rare condition with limited reports in the literature where guidelines for its optimal treatment are not well established.

Retroperitoneal Air after ERCP with Sphincterotomy: Frequency and Clinical Significance —Retroperitoneal Air after Sphincterotomy

Background and Aim: After successful medical management of a patient with a clinical picture suggestive of post-sphincterotomy duodenal perforation, in which a computerized axial tomography (CAT) scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, concern arose as to the frequency of pneumoretroperitoneum following endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ES) and if any procedure dependent factors were associated with this problem. Aim: To assess the frequency and clinical significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy. Methods: Fifty consecutive patients, who had undergone ERCP with sphincterotomy, were submitted to abdominal CT examinations within 24 hours after completion of the procedure. One patient was with a large precut, but a failed ERCP was also included. The ERCP findings were unknown to the radiologist. Results: Seven (14%) of 50 patients showed CT findings of retroperitoneal air. All of them had uneventful post-procedural recovery. No clinical or laboratory abnormality was found in this group of patients. The presence of retroperitoneal air was not associated to the variables: precut, biliopancreatic disease type, endoscopic sphincterotomy length, additional endoscopic procedure (balloon exploration, gallstone extraction, stent insertion) or procedure duration. Conclusion: After ERCP with ES, retroperitoneal air is frequently found. In the absence of physical symptoms, retroperitoneal air is not clinically relevant and does not require specific treatment.