Accidental endoscopic piercing of the tongue with an Ovesco clip

A 77-year-old woman was sent to our center for radiological investigation of a suspect pancreatic lesion. A computed tomography (CT) scan with contrast had been performed of a malignant pancreatic neoplasia invading mesenteric vessels and conditioning jaundice. Under deep sedation with intravenous propofol (Diprivan; Astra Zeneca, Wilmington, Delaware, North Carolina, USA), the patient underwent endoscopic ultrasound to stage the lesion. During the passage of the endoscope between the stomach and duodenum, we observed a 15-mm diameter, full-thickness lesion on the posterior wall of the duodenal bulb, just above the duodenal knee.

Using an operative gastroscope (Pentax EG 3490K; Pentax, Hamburg, Germany), we tried to place on the perforation an 11-mm clip with sharp teeth (Ovesco Endoscopy, Tübingen, Germany) but, during the passage of the mouthpiece, the clips were accidentally released on the tongue ([Fig. 1]). This was probably due to too much thread tension release. The clip was immediately removed manually.

Fig. 1 Ovesco clip accidentally released on the tongue.

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