Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy

Abstract

Figure 1. Endoscopic images of an ampullary tumor. White-light image shows swelling of the ampulla to 12 mm in diameter, with recession in the center of the tumor. Endoscopic papillectomy is an alternative to surgery for tumors of the ampulla of Vater. Adverse effects of the procedure, however, include pancreatitis, bleeding, and papillary stenosis, as well as occasional perforations, which are sometimes challenging to treat endoscopically. A novel endoscopic closure device, the Over-the-Scope Clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) System, has increased the ability of the therapeutic endoscopist to close gastrointestinal luminal defects and treat gastrointestinal bleeding. Here, we describe a case in which a postendoscopic papillectomy perforation was successfully resolved using the OTSC. A 58-year-old woman was referred to our hospital for treatment of an ampullary tumor with slight epigastric discomfort. Upper gastroendoscopy using a side-view endoscope showed swelling of the ampulla to 12 mm in diameter (Fig. 1). The tumor was relatively small without ulceration, and the initial forceps tumor biopsy conducted at the previous hospital did not show features of malignancy. CT showed no lesions that resembled metastases. EUS showed that the tumor had not invaded the common bile duct, main pancreatic duct, or duodenal wall (Fig. 2). Therefore, it was treated by endoscopic papillectomy. Using a snare, we resected the ampullary tumor endoscopically with a clear margin (Fig. 3). During the placement of plastic stents, the lower part of remnant submucosa under the resection area exhibited tearing (Fig. 4) and expanded, with free air leakage into the retroperitoneal space (Fig. 5). Endoscopic clipping failed to close the perforated submucosa because of difficulty in maneuvering using the side-view endoscope; therefore, an OTSC mounted on a direct-view endoscope was used to close the region. The edges of the fistula were grasped with the twin grasper. The fistula was pulled into the cap with “scope channel suction,” followed by deployment of a “bear claw” clip. The OTSC closure was performed to avoid involvement of the bile duct and pancreatic duct stents. The fistula was entirely closed, and air no longer leaked from the lumen (Fig. 6). Finally, a biliary drainage tube, which was optional and allowed us to confirm no bile leakage on cholangiography a few days later, was inserted