Endoscopic success. Healing a perforated duodenal ulcer with suturing using the re-openable clip over the line method. Generally, the treatment of perforated duodenal ulcers can be divided into surgical and conservative treatment. If peritonitis is present and ascites are limited, a nasogastric tube may be inserted and antacid and antibiotics may be administered to improve the condition conservatively. However, surgery is often required. Duodenal ulcer perforation, which often have a hard ulcer base, is difficult to suture endoscopically. And few reports to date have addressed endoscopic management of duodenal ulcer perforations. Various methods for mucosal defect closure after endoscopic treatment have been reported. Recently, methods that allow the suturing of defect holes in all layers after endoscopic full-sexless resection have been developed. But these methods are mainly used after resection of tumors. This time, we report successful endoscopic treatment of duodenal ulcer perforation using a combination of the reported methods. Here, we present a case with a 49-year-old man with duodenal ulcer perforation. His medical history was chronic heart failure with very low ejection fraction. He had no history of helicobacter pylori infection. He was admitted to a hospital with respiratory distress and abdominal pain. Computed tomography revealed pneumonia and perforation of the upper GI tract, and systemic findings showed exacerbation of chronic heart failure. Computed tomography showed a large amount of ascites with free air, and upper GI endoscopy revealed a perforated duodenum ulcer at the superior duodenum angle. This patient was considered to need surgical treatment. However, due to his poor general condition with severe heart failure and pneumonia requiring oxygen, general anesthesia and surgical treatment were considered difficult. Therefore, we applied previous reported procedure and attempted to close and maintain the perforation site endoscopically. The perforation site was located at the superior duodenum angle. First, we coagulated the massing of the perforation site by using APC. Suturing was attempted using a strong glass bearing clip with a sharp jaw. We firmly grasped the edge of the perforation and began suturing. The perforation site was firmly closed. However, one week later, the suture site was detached completely. So next, we attempted suturing with clips with arms on the left, right and center. These clips collapse and pull the mucosa using two independent clip arms and middle claw. After grasping both claws, deploy the clips simultaneously. We obtain an endoscopic closure. However, four days later, the perforated area was detached again. This time, we selected a re-operable clip over the live method called ROM. We catalyzed the massing of the perforation with APC. Then, the PGA sheets were applied to the perforation site. We attached the PGA sheet with fibering glue using a catheter. Then, spraying the slumping. Subsequently, we started the ROM from the edge of the region. We temporarily grasped only one osomalzy and pulled the thread to the other side. The next clip was deployed to the opposite side and pulled the entire scope to the side of the previous clip. The same procedure was repeated one after another. And perfect suturing was performed. The suture of the ulcer base remained rigid after one week. Therefore, the patient avoided surgery and achieved healing. Even if strong clips were used, the method of suturing the perforation end-to-end with a single clip did not allow for healing. Once a closed wound was achieved, it fell easily within a few days. So we have three points to close the perforation site successfully. 1. Totalizing the margins of the perforation site with APC. 2. Filling with a PGA sheet. 3. Suturing the perforation site using roll. In conclusion, with some ingenuity, endoscopic suture treatment of duodenal ulcer perforation using roll may be a good treatment option.

endoscopic approach

perforated duodenal ulcer

Re-openable Clip Over the Line

thermal coagulation

PGA sheet