Successful endoscopic closure using novel clips for a duodenal perforation caused by an endoscopic ultrasound scope

Iatrogenic duodenal perforation is a serious complication of endoscopic procedures. Surgical intervention is commonly used to manage such perforations, with endoscopic intervention only recommended immediately post-perforation [1]. Conventional endoclips are usually inadequate to completely close large perforations [2]. The over-the-scope (OTS) clip system (Ovesco Endoscopy AG, Tübingen, Germany) has limited availability and is technically complex and expensive.

The MANTIS Clip (Boston Scientific, Marlborough, Massachusetts, USA) is a novel through-the-scope (TTS) clip that is reopenable and rotatable; the sharp claws were designed to grasp tissue securely, overcome the slippage issues of conventional clips, and allow closure of large defects ([Fig. 1]). They have previously been used for closure of defects after endoscopic resection [3] [4]. Herein, we report the use of this novel clip to perform successful endoscopic closure of a duodenal perforation caused by an endoscopic ultrasound (EUS) scope ([Video 1]).

Fig. 1 Photograph showing the tip of a MANTIS Clip (Boston Scientific, Marlborough, Massachusetts, USA), which has sharp claws, like the forelegs of a mantis.

Endoscopic closure of a duodenal perforation caused by insertion of an endoscopic ultrasound scope using novel reopenable through-the-scope clips.Video 1

An 82-year-old woman underwent EUS-guided tissue acquisition of a pancreatic head mass. Perforation occurred during the insertion of the EUS scope from the duodenal bulb to the second portion. The EUS scope was immediately removed, and a forward-viewing endoscope was inserted, which confirmed an approximately 10-mm perforation at the superior duodenal angle ([Fig. 2] a, b). Because of the size of the perforation, we used a MANTIS clip to attempt to close it. The normal mucosa at the proximal edge was grasped and pulled towards the anal edge using endoscopic manipulation. The clip was slowly reopened and the two edges were approximated. After confirming that both edges had been securely grasped, the clip was deployed. This procedure was repeated three times, and complete closure of the perforation was achieved in a total closure time of 10 minutes ([Fig. 2] c). Subsequently, the patient’s clinical course was uneventful, with oral fluid intake resuming after 2 days and discharge 7 days post-perforation.

Fig. 2 Endoscopic images showing: a, b an approximately 10-mm perforation that occurred during insertion of an endoscopic ultrasound scope; c the appearance after complete closure using three of the novel reopenable through-the-scope clips.

This novel clip could be a technically simple and effective option for the endoscopic closure of iatrogenic perforations.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Paspatis GA, Arvanitakis M, van Hooft JE. et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020. Endoscopy 2020; 52: 792-810
• 2 Khokhar OS, Nguyen DT, Haddad NG. et al. Endoscopic management of iatrogenic duodenal perforation with linear-probe echoendoscope. Gastroenterol Hepatol (NY) 2010; 6: 657-959
• 3 Ueda S, Kawata N, Ono H. et al. Closing the defect after gastric endoscopic full-thickness resection with a novel closure device. Dig Endosc 2024; 36: 742-743
• 4 Shigeta K, Kawata N, Ono H. et al. Novel clip closure technique for a large mucosal defect with anchor-pronged clips after duodenal endoscopic submucosal dissection. Dig Endosc 2024; 36: 849-850

Publication History

Article published online:
13 November 2024