Closing a fistula using clips with a duodenoscope is difficult [1]. However, if a defect cannot be seen with a straight endoscope, it can sometimes
be easily observed by changing to a duodenoscope. Therefore, a reliable defect closure
method using a duodenoscope is desired. We devised a method called the “reopenable-clip
over-the-line method” (ROLM), wherein complete closure can be achieved by placing
clips on one side of the defect edge [2]
[3]. Herein, we describe the first case of defect closure using ROLM with duodenoscopy.
The patient was a man in his 60s who developed a retroperitoneal abscess after acute
pancreatitis; the abscess and horizontal part of the duodenum were perforated ([Fig. 1], [Video 1]). Because the perforation site was difficult to observe with a direct endoscope,
we attempted to perform a simple clip closure using a wire-guided reopenable-clip
closure with a duodenoscope [4]. However, separation of the wound was confirmed using fluoroscopy 2 weeks after
the procedure. The fistula was closed using ROLM with a duodenoscope (JF-260V; Olympus).
A clip with a line (SureClip: MicroTech; PE Line: Super X-wire 1.5, DUEL Co.) was
placed on the edge of the fistula. The line was then threaded through one of the teeth
of the re-openable clip, and the clip was inserted. The line was then pulled while
the edge of the fistula was grasped using a clip. After confirming that the clips
were brought close together, they were placed. The fistula closed completely after
the procedure was repeated. Subsequently, several clips were used to hold the line
in place. Finally, the line was cut using the modified locking-clip technique [5]. Complete closure of the fistula was confirmed using fluoroscopic imaging.
Fig. 1 Actual fistula closure using a duodenoscope and the ROLM. a Duodenum and retroperitoneal abscess seen on fluoroscopy. Leakage from the duodenal
fistula to the retroperitoneum is seen (yellow arrow). b Endoscopic image of the fistula using a duodenoscope. c First clip with line placed at the edge of the fistula. d A re-openable with a line threaded through one tooth is placed on the defect edge.
e The defect after repeated ROLM. f Fluoroscopy after ROLM fistula closure with no leakage into the retroperitoneum.
Abbreviation: ROLM, reopenable-clip over-the-line method.
Defect closure using a duodenoscope and the reopenable-clip over-the-line method.Video
1
Endoscopy_UCTN_Code_TTT_1AO_2AI
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