Endoscopy 2017; 49(11): E279-E280
DOI: 10.1055/s-0043-115891
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Surgery avoided by the use of over-the-scope clips for severe duodenal complications associated with endoscopic mucosal resection

Noriko Nishiyama
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Hirohito Mori
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Hideki Kobara
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Shintaro Fujihara
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Nobuya Kobayashi
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Tatsuo Yachida
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Tsutomu Masaki
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
03 August 2017 (online)

During endoscopic treatment for duodenal neoplasm, hazardous complications such as perforation and bleeding sometimes occur owing to the anatomical characteristics of the duodenum [1] [2] [3]. Although surgical repair has been traditionally required for these complications, the procedure is invasive and complicated [4]. A currently available over-the-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) has provided excellent outcomes for gastrointestinal refractory bleeding and full-thickness defects [5]. Here, we describe a notable case in which iatrogenic duodenal complications could be managed with OTSCs.

A 56-year-old man presented with a duodenal adenoma that showed a reddish and flat elevated lesion, approximately 10 mm in diameter, located in the posterior wall of the second duodenal portion ([Fig. 1]). After submucosal injection, cap-assisted endoscopic mucosal resection (EMR) was performed under carbon dioxide insufflation. A large full-thickness perforation, 20 mm in diameter, occurred ([Fig. 2 a]), and spurting arterial bleeding was seen ([Fig. 2 b]). The bleeding was accompanied by hemorrhagic shock and was immediately controlled using hemostatic forceps (Coagrasper; Olympus, Tokyo, Japan). OTSCs were then applied to close the defect at the perforation site, after obtaining informed consent. Grasping forceps (Twingrasper; Ovesco Endoscopy) were used to approximate the edges of the large defect. The defect was mostly closed by one OTSC (t type, 9 mm), and the remaining defect was closed by an additional OTSC using simple suction ([Fig. 3], [Video 1]).

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Fig. 1 An upper gastrointestinal endoscopy revealed a reddish and flat elevated lesion (yellow allows), approximately 10 mm in diameter, located in the posterior wall of the second duodenal portion.
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Fig. 2 Endoscopic views. a A large full-thickness perforation, 20 mm in diameter, occurred with exposure of the muscle layer after performing cap-assisted endoscopic mucosal resection. b Spurting arterial bleeding was seen at the edge of the perforation site.
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Fig. 3 The whole defect was completely closed by two over-the-scope clips (t type, 9 mm).

Video 1 Cap-assisted endoscopic mucosal resection was performed for a tumor located in the second duodenal portion. A large full-thickness perforation occurred with spurting arterial bleeding. After complete hemostasis was achieved using hemostatic forceps, the defect was successfully closed by two over-the-scope clips.


Quality:

A radiographic examination 5 days later confirmed no leakage at the perforation site ([Fig. 4]). The patient was discharged without additional interventions 19 days later. A histological examination revealed curative resection of a tubular adenoma with moderate-grade dysplasia. Follow-up endoscopy 2 months later confirmed complete closure of the defect ([Fig. 5]).

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Fig. 4 A radiograph confirmed no leakage at the perforation site 5 days later. The red arrows show the perforation site closed by over-the-scope clips.
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Fig. 5 Complete closure of the defect was confirmed 2 months later.

This case demonstrates that OTSC rescue may be a minimally invasive therapy option for a life-threatening complication such as a large duodenal perforation with spurting bleeding.

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