Innovative Management of Duodenal Perforation Using New Endoscopic Techniques and Equipment

A 64-year-old woman presented with severe right upper quadrant abdominal pain and vomiting. Physical examination revealed guarding with rebound tenderness. A computed tomography scan revealed a large duodenal diverticulum with pneumoperitoneum, suggesting a spontaneous duodenal perforation. The patient underwent an emergency exploratory laparotomy, and a retroperitoneal drainage tube was placed. After multidisciplinary discussion, an endoscopic evaluation and possible treatement were planned. Initial esophagogastroduodenoscopy revealed a 5 cm diverticulum in the second part of the duodenum with a 1 cm perforation in his apex. The ampulla of Vater was located proximally. A contrast enterogram confirmed extravasation at the perforation site. The defect was partially closed with an intradiverticular Over The scope Clip (OTS-clip), followed by another OTS-clip to close the diverticular rim. Intra-operative contrast injection showed no extravasation.A follow-up CT scan on postoperative day 4 showed a persistent leak, necessitating another endoscopic closure. Using a therapeutic gastroscope and an Xtack suture system (Boston Scientific), the diverticular rim was completely closed alongside the OTS-clip. No contrast extravasation was observed on the enterogram. Additionally, a plastic pancreatic stent, nasobiliary drain, and nasojejunal tube were placed to aspirate duodenal secretions. The patient recovered without postoperative adverse events. At 1 week after endoscopic closure, an upper gastrointestinal series showed resolution of the leak, allowing removal of the biliary drainage and nasojejunal tube, and the patient started oral feeding. At 6 weeks, a follow-up CT scan confirmed complete closure of the defect. In conclusion, the present technique might be useful for endoscopic treatment of duodenal diverticular perforations [1] [2].

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Artikel online veröffentlicht:
27. März 2025

• References

• 1 Arayakarnkul S. et al. A Tale of 2 Tics: Endoscopic Treatment of Perforated Periampullary Diverticulum Within a Giant Duodenal Diverticulum ACG Case Rep J. 2023
• 2 Shimada A. et al. Perforated duodenal diverticulum successfully treated with a combination of surgical drainage and endoscopic nasobiliary and nasopancreatic drainage: a case report Surg Case Rep. 2020