Iatrogenic duodenal perforation endoscopic closure double trouble double closure presenter Dr. Sawan Bopanna the authors have nothing to disclose. 47 year old male patient presented with severe pain abdomen since three days and breathlessness he had raised amylase and lipase and ultrasound showed features of pancreatitis and cholelithiasis so was diagnosed with acute pancreatitis of biliary etiology. While admitted in the hospital he was found to have SIRS with the TLC of 20,000 tachycardia tachypnea spikes of fever and increasing oxygen requirement and worsening respiratory function. His liver functions were deranged with the total bilirubin of 15.5 and SGOT SGPT and alkaline phosphatase showing raised values. In view of a deranged LFT he underwent MRI which showed features of pancreatitis gallstones with a cystic duct calculi and dilated CBD with filling defects likely small calculi in the distal CBD. There was a possibility of biliary sepsis complicating acute pancreatitis and it was planned to place a CBD stent. CBD was cannulated selectively. Spintrotomy was done. Balloon sweeps of the CBD were done. Following one of the CBD sweeps a dodenal perforation was suddenly noted. Biliary drainage was secured with the placement of a plastic stent. The dodenal perforation was then examined. A large dodenal perforation was noted which was the perforation number one and just proximally to this perforation another perforation was noted to our horror which was dodenal perforation 2. As part of immediate management a surgical review was called for. In view of ongoing pancreatitis surgery was associated with morbidity and high risk of mortality. It was therefore planned to attempt endoscopy closure. The first defect was larger in size and not amenable to closure by only clips. Therefore it was decided to use a loop and clip closure technique to close the first defect. The second defect was planned to be closed with an OTSC. For a loop and clip closure an endo loop was first placed in dodenum. Endo loop was fixed on all sides of the defect using hemoclips. Hemoclips were placed at multiple points and the loop was clipped to the mucosa. Once the loop was clipped to the edges of the defect, the end loop was tightened pulling the clips together leading to closure of the defect. A small residual defect was closed with a hemoclip. The second duodenal defect was planned to be closed with an OTSC. An OTSC was placed over the defect. The defect was suctioned and the clip applied. A wire was placed across the defects and a nasojejunal tube was placed for feeding. The patient was then managed conservatively. There were no signs of peritonitis and nasojejunal feeds were started after 24 hours. A CT with oral contrast was done which showed no active extravasation of contrast from duodenum. The clips were seen in-situ. Pancreatitis was managed conservatively, LFT normalized and fever gradually settled. Nasojejunal tube was removed after 7 days and oral feeds were started. The patient was discharged on day 14. Some of the challenges faced are as follows. It was difficult to use the loop and clip closure technique in the duodenum due to a small lumen and a reduced working space. The presence of a biliary stent was causing obstruction to working in a small place. The mucosa was edematous secondary to pancreatitis and was difficult to close. To conclude, in iatrogenic duodenal perforations endoscopic closure may be successful, may be considered when predicted outcomes of surgery are dismal due to associated comorbid conditions. Loop and closure technique is technically challenging, but may be considered for large defects. When adverse events occur during endoscopy all is well that ends well. Thank you.

acute biliary pancreatitis

iatrogenic duodenal perforations

endoscopic closure

loop and clip technique

OTSC