Repair of an Endoscopic Retrograde Cholangiopancreatography-Related Large Duodenal Perforation Using Double Endoscopic Band Ligation and Endoclipping

Abstract

Endoscopic closure techniques have been introduced for the repair of duodenal wall perforations that occur during endoscopic retrograde cholangiopancreatography (ERCP). We report a case of successful repair of a large duodenal wall perforation by using double endoscopic band ligation (EBL) and an endoclip. Lateral duodenal wall perforation occurred during ERCP in a 93-year-old woman with acute calculous cholangitis. We switched to a forward endoscope that had a transparent band apparatus. A 2.0-cm oval-shaped perforation was found at the lateral duodenal wall. We repaired the perforation by sequentially performing double EBL and endoclipping. The first EBL was performed at the proximal edge of the perforation orifice, and two-thirds of the perforation were repaired. The second EBL, which also included the contents covered under the first EBL, repaired the defect almost completely. Finally, to account for the possible presence of a residual perforation, an endoclip was applied at the distal end of the perforation. The detection and closure of the perforation were completed within 10 minutes. We suggest that double EBL is an effective method for closure.

Recent advances in prevention and management of endoscopic retrograde cholangiopancreatography-related duodenal perforation.

“…For small perforations (< 1 cm), a single endoscope clip is sufficient. For larger perforations (> 1 cm), it is best to combine Endoloops and Endoclips, double endoscopic band ligation and Endoclipping, and multiple endoscopic devices [ 31 , 32 ]. In double lumen endoscopically, a plurality of titanium clips should be used to secure the snare to the perforated edge before tightening the snare.…”