My name is Mikael Quattrone and I will be presenting a video case report on a helical TAC closure of a failed duodenal perforation repair. Listed are our disclosures. Perforated duodenal ulcers often require emergency surgical intervention, particularly for non-contained perforations and in patients with signs of sepsis. However, there is around a 9.8% failure rate associated with traditional surgical repair. Endoscopic management is a minimally invasive approach that can be utilized in clinically stable patients and those who have ongoing leaks following initial operation. A variety of endoscopic options exist, including through and over the scope clips and endoscopic suturing devices. However, larger defects in difficult anatomic locations can create challenges for successful endoscopic repairs. In this video case report, we describe the use of a helical TACing system for the management of an ongoing duodenal leak following prior surgical repair. The patient is a 74-year-old female with COPD and active smoking history who presented with subjective shortness of breath. A CT scan demonstrated evidence of pneumoperitoneum and associated free fluid concerning for possible perforation. She was taken emergently for an exploratory laparotomy. A 2-centimeter D1 perforation was identified on the anterior duodenal wall. A modified grand patch repair with drainage was performed with a negative EGD and leak test. Postoperatively, she was noted to have high ongoing JP drain output. A CT scan with PO contrast obtained on postoperative day 5 demonstrated contrast extravasation within the lateral duodenal space as demonstrated here. Given this, she was taken to the OR for endoscopic evaluation with our surgical endoscopy team. The scope was advanced into the duodenum. The suture line of her previous primary repair was inspected. The scope was in advanced distally and a second non-blading ulcer was identified. A clear cap was in place over the end of the scope in order to better evaluate the suture line. The sutures had appeared to have diffusely loosened over the repair site. Contrast was injected into the area which identified a leak at the right lateral aspect of the repair. Given the nature of the leak, we did not feel as though this area could be adequately closed with a single over the scope clip. We also felt that the location of the ulcer would not allow for closure using an endoscopic suturing device. We therefore elected to close the suture line with helical tacks. Starting at the distal aspect of the defect, a preloaded helix tack was deployed into the mucosa. Moving in a figure of eight fashion, each subsequent tack was then deployed. The suture was then tightened to ensure adequate tension. After the final tact was deployed, the suture cinch was released, creating final tension and locking the suture into place. Moving approximately along the suture line, a second tacking system was utilized. In a similar fashion, each tack was deployed and served as individual fixation points for the closure. As the tacks were deployed, the suture was again tightened, ensuring appropriate re-approximation. The suture cinch again locked the suture into place. Upon reinspection, there continued to be a loose suture at the proximal aspect of the defect that was not well approximated. The decision was then made to place an additional helix tacking system. A third and final system was then deployed. Care was taken to ensure appropriate fixation and that the re-approximation was carried out along the entire length of the remaining defect. Biopsies were then taken of the second duodenal ulcer. Next, two endoscopic clips were placed over the ulcer to help prevent any future bleeding or complication. The repair site was once again inspected to ensure adequate closure. Additional re-approximation was provided using endoscopic clips. These clips were placed in between each of the three individual tacking systems. This allowed for additional re-approximation of the suture line. There was no persistent leak present upon completion of the case. Finally, distal feeding access was placed and the scope was withdrawn. A repeat CT obtained on post-operative day four following endoscopic closure was negative for an ongoing leak. She continued to progress appropriately and was discharged to an LTAC on hospital day 15. She was doing well at her one-month hospital follow-up without evidence of an ongoing leak. Helical tack closure is a safe endoscopic management option for persistent duodenal leaks following traditional surgical management. This case highlights the importance of familiarity with multiple endoscopic treatment modalities as well as the importance of interdisciplinary communication for optimal patient management. Listed are our references.

helical TAC closure

persistent duodenal leak

surgical repair

endoscopic evaluation

interdisciplinary collaboration