Closure of Endoscopic Perforations With Endoscopic Clips

Richard S. Kwon, MD, David L. Carr-Locke, MD, FRCP Series Editor: David L. Carr-Locke, MD, FRCP

Disclosures

December 13, 2002

In This Article

Introduction

Perforation is a known, major complication of upper and lower endoscopy. The incidence of perforation is higher during therapeutic vs diagnostic procedures. Management of perforation ranges from conservative treatment to operative repair. We describe 3 cases of perforation identified at the time of endoscopy that were successfully closed with endoscopic clips.

Case 1

A 64-year-old man presented for an outpatient endoscopic retrograde cholangiopancreatography (ERCP) after a retained common bile duct stone and dilated extrahepatic ducts were found on magnetic resonance cholangiopancreatography during work-up for recurrent abdominal pain. The patient had a history of Billroth II procedure for a gastric ulcer and multiple laparotomies to resect or repair anastomotic strictures. He also had 2 previous balloon dilations of recurrent, symptomatic anastomotic strictures in recent months.

During intubation of the afferent limb, a perforation was noted in the jejunum (Figure 1a). Five endoscopic clips were applied to close the defect (Figure 1b). Closure was confirmed by lack of extravasation of contrast.

Figure 1a.

Perforation in the jejunum identified during ERCP. Serosa is visible in background.

Figure 1b.

Five endoscopic clips were used to successfully close the perforation.

The patient complained of abdominal pain and was admitted for observation and intravenous antibiotics. A computed tomography (CT) scan of the abdomen showed intraperitoneal and retroperitoneal air. His pain quickly improved and his liver function tests normalized, presumably due to passage of the retained stone. Results of ultrasound confirmed his common bile duct to be of normal caliber and without stones. His abdominal exam remained benign and he was discharged after 8 days.

Case 2

An 82-year-old woman underwent an endoscopic gastroplication procedure using endoscopic clips. The patient had a history of Nissen fundoplication that required a repeat repair. Despite maximal proton-pump inhibitor doses, the patient continued to complain of reflux symptoms and dysphagia. She did not wish to undergo surgery again and requested an alternative method of therapy.

She underwent an upper endoscopy that revealed a tortuous esophagus, a 6-cm hiatal hernia, and changes consistent with the previous Nissen procedure. Two plications were deployed without difficulty. Upon retraction of the endoscope, however, there was a perforation noted just superior to the Nissen wrap (Figure 2a). Eight endoscopic clips were applied without complication (Figure 2b), and the patient was admitted for observation.

Figure 2a.

Esophageal perforation superior to the Nissen fundoplication (arrow) identified after gastroplication.

Figure 2b.

Eight endoscopic clips were used to successfully close the defect.

A chest radiograph revealed neither mediastinal air nor a pneumothorax. A CT scan of the chest showed minimal mediastinal air and no extraluminal contrast. Barium swallow performed on hospital day 5 was negative. The patient tolerated a soft diet and was discharged home on day 6.

Case 3

A 57-year-old man with a family history of colon cancer and a history of previous polypectomies was referred to our institution for a colonoscopy after 2 unsuccessful attempts to remove a sessile tubulovillous adenoma in the cecum. A methylene blue/saline-assisted polypectomy of a 1-cm sessile cecal polyp (Figure 3a) was successfully performed, but a perforation was immediately noted at the site of the polypectomy (Figure 3b).

Figure 3a.

A 1-cm sessile cecal polyp after submucosal methylene blue and saline injection. Two previous attempts to remove this polyp were unsuccessful. Previous pathology was reported as tubulovillous adenoma.

Figure 3b.

Perforation at site of polypectomy.

Eight endoscopic clips were used to close the defect (Figure 3c). The patient was admitted for observation and intravenous antibiotics. His abdominal examination remained benign and he was discharged after 2 days, tolerating a regular diet. Results of pathology showed that the polyp was a 1.7 x 1.2 x 0.7-cm adenoma with clear margins.

Figure 3c.

Eight endoscopic clips were used to successfully close the perforation. The polyp was identified as an adenoma with clear margins.

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