Gazelakis Kathryn, Lovett Grace, Chen Robert, Al-Habbal Yahya, Nalankilli Kumanan
Department of Medicine, Monash University, Melbourne, Victoria, Australia.
Department of Gastroenterology and Endoscopic Services, Western Health, Melbourne, Victoria, Australia.
Case Rep Gastroenterol. 2022 Mar 28;16(1):186-194. doi: 10.1159/000523894. eCollection 2022 Jan-Apr.
Iatrogenic Stapfer type-1 duodenal perforations during endoscopic retrograde cholangiopancreatography (ERCP) typically necessitate surgical management and carry significant morbidity and mortality risk. Here, we present a case of a large duodenal perforation during ERCP managed endoscopically with an over-the-scope clip (OTSC) and describe the subsequent post-procedural management. An 80-year-old woman presented to the emergency department with acute cholangitis. Abdominal ultrasound scan revealed a dilated biliary tree with echogenic material in the common hepatic and intrahepatic ducts. The patient proceeded to ERCP, where filling defects consistent with stones were found in the proximal main bile duct on cholangiogram. Stone retrieval was complicated by a large iatrogenic perforation of the infero-lateral duodenal wall, distal to the major ampulla (Stapfer type-1). Following unsuccessful attempts to close the defect using through-the-scope clips, a decision was made to attempt closure endoscopically using an OTSC. The duodenoscope was exchanged for a forward-viewing gastroscope mounted with the OTSC. The perforation defect was fully suctioned into the cap and the clip was successfully deployed. Subsequent on-table fluoroscopy with contrast injection did not demonstrate any extra-luminal contrast leak. The patient developed a post-procedure infra-duodenal collection, however, made a complete recovery with bowel rest, negative pressure regulation at the site of the OTSC using a dual-lumen nasogastric/nasojejunal feeding tube and intravenous piperacillin-tazobactam. Thus, OTSCs potentially offer a safe and effective endoscopic treatment modality for the immediate management of ERCP-related Stapfer type-1 duodenal perforations.
内镜逆行胰胆管造影术（ERCP）期间发生的医源性斯塔尔弗1型十二指肠穿孔通常需要手术治疗，且具有较高的发病率和死亡率风险。在此，我们报告一例在ERCP期间发生的大型十二指肠穿孔，通过内镜下使用套扎器（OTSC）进行处理，并描述后续的术后管理情况。一名80岁女性因急性胆管炎就诊于急诊科。腹部超声扫描显示胆管树扩张，肝总管和肝内胆管有回声物质。患者接受了ERCP，在胆管造影中发现近端主胆管存在与结石相符的充盈缺损。取石过程中，十二指肠壁下外侧发生了一个大型医源性穿孔，位于十二指肠大乳头远端（斯塔尔弗1型）。使用内镜夹试图闭合缺损未成功后，决定尝试使用OTSC进行内镜下闭合。将十二指肠镜换成装有OTSC的前视胃镜。将穿孔缺损完全吸进帽内，成功部署了夹子。随后在术中进行的透视造影检查未显示任何腔外造影剂渗漏。然而，患者术后出现十二指肠下积液，通过禁食、使用双腔鼻胃/鼻空肠喂养管对OTSC部位进行负压调节以及静脉注射哌拉西林-他唑巴坦，患者完全康复。因此，OTSC可能为ERCP相关的斯塔尔弗1型十二指肠穿孔的即时处理提供一种安全有效的内镜治疗方式。
