Matsuoka Mana, Kobayashi Katsumasa, Okura Yukito, Mochida Tomohiro, Nozaka Takahito, Sato Ayako, Yauchi Masato, Matsumoto Taichi, Furumoto Yohei, Horiuchi Takao, Asano Toru
Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
Case Rep Gastroenterol. 2021 Mar 1;15(1):253-261. doi: 10.1159/000512474. eCollection 2021 Jan-Apr.
Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation <15 mm was identified in the superior duodenal horn. We attempted an endoscopic closure with multiple endoclips but could not completely close the perforation site. Strips of bioabsorbable polyglycolic acid (PGA) sheets were placed over the gaps between the endoclips with biopsy forceps and fixed in place with fibrin glue, completely covering the perforation site. Two days after the procedure, the perforation site had closed. Nine days later, endoscopic biliary stenting was performed. The patient was diagnosed with pancreatic cancer through bile cytology, and the optimal supportive care for her age was selected. Endoscopic tissue shielding with PGA sheets and fibrin glue is increasingly being reported for use during gastrointestinal endoscopic procedures. In this case, surgery was avoided due to successful endoscopic treatment using endoclips and PGA sheets with fibrin glue without OTSC. This method may be useful for repairing acute duodenal perforations during EUS and should therefore be known to pancreatobiliary endoscopists.
内镜超声检查（EUS）期间发生的急性十二指肠穿孔是一种严重的并发症。对于十二指肠穿孔，如内镜下夹闭等传统的内镜治疗方法并不理想；最近，有人报道了套扎式内镜夹（OTSC）的有效性。一名91岁女性因黄疸为主诉被转诊至我院。增强计算机断层扫描显示胰头有一个2厘米的肿块；我们计划进行EUS引导下细针穿刺抽吸。在二氧化碳充气下使用线性超声内镜从十二指肠球部探寻穿刺路径时，十二指肠腔内突然充满血液。在十二指肠上角发现一个小于15毫米的穿孔。我们尝试用多个内镜夹进行内镜闭合，但未能完全封闭穿孔部位。用活检钳将生物可吸收聚乙醇酸（PGA）片条放置在内镜夹之间的间隙上，并用纤维蛋白胶固定到位，完全覆盖穿孔部位。术后两天，穿孔部位已闭合。九天后，进行了内镜下胆管支架置入术。通过胆汁细胞学检查诊断该患者患有胰腺癌，并为其年龄选择了最佳的支持治疗。越来越多的报道称，在胃肠内镜检查过程中使用PGA片和纤维蛋白胶进行内镜组织屏蔽。在本病例中，由于使用内镜夹和带纤维蛋白胶的PGA片成功进行了内镜治疗，无需OTSC，从而避免了手术。这种方法可能对EUS期间急性十二指肠穿孔的修复有用，因此胰胆内镜医师应该了解。
