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DOI: 10.1055/a-2479-1311
Rescue endoscopic ultrasound-guided gastroenterostomy with closing of the duodenum in case of duodenal perforation
A duodenal perforation is a life-threatening condition [1] with a mortality rate between 8% to 25% [2]. We will present two cases of duodenal perforations managed endoscopically.
Our first case is a 74-year-old man admitted for ulcer-induced peritonitis after nonsteroidal ani-inflammatory drug ingestion. An abdominal computed tomography (CT) scan showed a pneumoperitoneum with periduodenal infiltration. A laparoscopic exploration confirmed peritonitis without duodenal perforation. Two days later, the patient presented with a resurgence of abdominal pain, prompting an upper endoscopy, which found a necrotic cavity at the first part of the duodenum treated with a 12-cm fully covered duodenal prosthesis. The clinical evolution was unfavorable with the persistence of the duodenal perforation. We decided to perform an endoscopic ultrasound (EUS)-guided gastrojejunostomy with a lumen-apposing metal stent (LAMS) (Hot AXIOS 20 mm; Boston Scientific, Marlborough, Massachusetts, USA). The pylorus was closed in the same session with an over-the-scope (OTS) clip (Ovesco Endoscopy AG, Tübingen, Germany). The patient was discharged after 2 weeks after a rapid recovery ([Video 1], [Fig. 1]).
Our second case is a 54-year-old man admitted to the intensive care unit for severe acute Balthazar E pancreatitis with multi-organ failure, a duodenal perforation in communication with a large necrotic retroperitoneal cavity, extra-hepatic bile ducts destruction, and a pancreatic fracture. Two EUS-guided cystogastrostomies with LAMS (Hot AXIOS 10 mm; Boston Scientific) were done to treat paragastric collections. The biliary defect was treated with a fully covered metallic stent. After one month, the retroperitoneal cavity increased in size with the resurgence of sepsis. An EUS-guided gastrojejunostomy with LAMS (Hot AXIOS 20 mm; Boston Scientific) was performed, with closing of the genu superius with an OTS clip (Ovesco Endoscopy AG) and positioning an Endo-SPONGE (B. Braun, Melsungen, Germany) into the duodenal bulb. Progress was excellent with a discharge from acute care and complete removal of the Endo-SPONGE after 2 weeks.
These two successful EUS-guided gastro-entero-anastomoses with LAMS and endoscopic closing of the duodenum open up a new alternative when duodenal perforation occurs and cannot be treated surgically.
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Publication History
Article published online:
04 December 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Weledji EP. An overview of gastroduodenal perforation. Front Surg 2020; 7: 573901
- 2 Ansari D, Torén W, Lindberg S. et al. Diagnosis and management of duodenal perforations: a narrative review. Scand J Gastroenterol 2019; 54: 939-944