Endoscopic treatment of duodenal perforation using a clipping device: case report and review of the literature.

Abstract: The standard treatment for gastrointestinal perforation secondary to an endoscopic procedure is surgical repair. Some authors advocate a conservative medical management. However, this approach may be associated with increased morbidity and mortality. We describe a case of duodenal perforation secondary to snare polypectomy that was successfully treated with endoclipping. Additional published case reports were reviewed. Current data suggest that endoclipping may be appropriate in the management of a select group of patients with iatrogenic gastrointestinal perforation.

Key Words: duodenal perforation, endoclips, endoclipping, gastrointestinal perforation

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Traditionally, gastrointestinal perforations secondary to endoscopic procedures have been managed surgically. (1), (2) Some authors (3), (4) advocate a nonsurgical approach in selective cases; however, this approach has a high failure rate and carries a significant risk of morbidity and mortality. Recently, few reports have described the use of an endoscopic clipping device to close traumatic or iatrogenic defects in the upper gastrointestinal tract. We describe a case of duodenal perforation after snare cautery excision of a polyp that was successfully treated by nonsurgical means using a clipping device.

Discussion

The standard treatment for a duodenal perforation involving the lateral or medial wall is immediate surgery. (3), (5) Some authors advocate medical management (observation and administration of antibiotics) in selected cases of uncomplicated small perforations. (3), (4), (6) However, this approach may be associated with a high failure rate (1-3) and an increased risk of complications including the need for salvage surgery and subsequent reoperations, a longer hospital stay, and death from sepsis. Thus, several authors advocate surgical repair in all cases of duodenal perforation because early operation is associated with fewer hazards than a delayed surgery. In general, current data suggest that small perforations associated with no or a small demonstrable leak can successfully be managed medically in the majority of patients.

[FIGURE 1 OMITTED]

An alternative to these two traditional approaches is the nonsurgical endoscopic treatment of perforations using an endoclipping device. In 1975, Hayashi et al (7) in Japan first described the application of metallic clips for marking lesions and for mechanical hemostasis in the gastrointestinal tract. In 1993, Binmoeller et al (8) in Germany were the first to report the use of endoclips to close a 5-mm perforation after snare resection of a gastric leiomyoma. Kaneko et al (9) used endoclips to treat two cases of duodenal perforation secondary to endoscopic mucosal resection of a carcinoid tumor. Baron et al (10) reported closing a duodenal perforation after sphincterotomy with six hemoclips. Roses et al (11) identified a duodenal perforation caused by a 10-French biliary stent. Interestingly, they fitted a cylindrical adapter cap of a band ligation device on the tip of the endoscope and used suction to approximate the margins of the defect to the endoscope and to help close the perforation with one clip. Other authors reported using endoscopic clipping to close defects in the upper or lower gastrointestinal tract that are traditionally managed surgically. Shimamoto et al (12) described the case of an esophageal perforation secondary to fishbone ingestion that was successfully closed by the application of metallic clips. Wewalka et al (13) used four clips to close a 15-mm longitudinal tear in the lower esophageal sphincter after pneumatic dilation for achalasia. Kim et al (14) closed a 7-mm gastric transmural defect after endoscopic mucosal resection of a dysplastic lesion, using six clips. Yoshikane et al (15) closed a 4-mm colonic perforation with five clips after endoscopic mucosal resection of a superficial colonic adenoma. In all these reported cases, the patients were subsequently managed by with holding oral intake; administration of IV antibiotics; and sometimes the use of a nasogastric tube, [H.sub.2]-blockers, and parenteral nutrition. Patients resumed oral intake between Day 2 and Day 17 after the procedure and were discharged shortly thereafter without the need for further intervention. After the treatment of the perforation, some of the patients underwent an imaging study (computed tomographic scan or Gastrografin swallow) that did not reveal any contrast leaks. Follow-up esophagogastroduodenoscopy showed complete healing of the perforation site and the clips were observed to dislodge spontaneously within 3 weeks of placement. A summary of reported cases is listed in Table 1.

The use of endoclips to close traumatic or iatrogenic perforation represents a new alternative to surgical or medical management. The success of endoclipping most likely results from the early recognition and closure of the defect. This prompt intervention minimizes leakage of digestive enzymes or bile and damage to surrounding organs (in the case of an upper gastrointestinal tract perforation) and fecal contamination of the peritoneal cavity (in the case of a colonic perforation). Compared with medical management alone, smaller amounts of bacterial contamination probably occur and may be better controlled by antibiotics. Moreover, the clipping procedure seems to be very safe. No clip-induced complications have been reported to date. The clips grasp only the mucosal and submucosal layers; (16) therefore, the occurrence of a significant tissue injury is very unlikely. The clips do not seem to impair healing or reepithelialization of the closed defect margins. There have been no reports of clip impaction or perforation.

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Still, some limitations to the use of endoclips apply. A successful outcome depends largely on the ability of the operator to deploy the clips in a timely fashion and thus on the comfort level of the endoscopist and his or her team in the endoclipping technique. An incomplete or delayed closure of the defect can result in considerable contamination of the surrounding spaces and defeat the purpose of the procedure. Despite the single report by Shimamoto et al (12) of successful endoscopic management of a noniatrogenic esophageal perforation, it is unclear whether this method is appropriate to manage perforation in a nonprepared gastrointestinal tract. In addition, only small perforations can currently be treated with clips, because the distance between fully opened disposable clip prongs is only 10 mm. Large defects still require surgery until larger clips or better endoscopic suturing devices become available. Finally, patients require close observation, and surgical backup must be available in case complications develop.

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In summary, we recommend treating perforations complicating gastrointestinal endoscopy with endoclips when the following conditions are present: 1) immediate recognition of the perforation at the time of the procedure, 2) the presence of a perforation small enough (currently <10 mm) to be amenable to endoclipping, 3) an endoscopy team competent in using endoclipping devices, and 4) the availability of surgical backup. The patient should be admitted to the hospital for observation, bowel rest, and IV antibiotics. Signs of peritonitis, SC emphysema, sepsis, and clinical deterioration should be monitored closely. We also recommend an imaging study to look for persistent fluid or contrast leak that might require surgical rescue if the patient's condition deteriorates.

Endoclips are expected to gain more use and popularity in the near future. They give the endoscopist a new therapeutic tool that some compare with the surgeon's suture. (17)

Key Points

* Use of endoclipping to close gastrointestinal perforation is presented.

* Indications for use of endoclipping to close perforation are discussed.

* Limitations to the use of endoclipping for perforation are discussed.

Table 1. Summary of case reports of endoclipping to close upper and
lower GI tract perforations (a)

Authors                         Site/size of perforation

Binmoeller et al, 1993 (8)  Stomach, 5 mm

Wewalka et al, 1995 (13)    LES, 15-mm longitudinal tear

Yoshikane et al, 1997 (15)  Colon, 4 mm

Kaneko et al, 1999 (9)      Duodenum (two cases)

Kim et al, 2000 (14)        Stomach, 7 mm

Baron et al, 2000 (10)      Duodenum

Roses et al, 2000 (11)      Duodenum, 10-French

Shimamoto et al, 2000 (12)  Esophagus, 20-mm longitudinal tear

Charabaty-Pishvaian and     Duodenum, 5 mm
  Al-Kawas (present study)

Authors                               Radiological findings

Binmoeller et al, 1993 (8)  Abdomen radiograph: free air

Wewalka et al, 1995 (13)    Gastrografin swallow: no contrast leak (b)

Yoshikane et al, 1997 (15)  NA

Kaneko et al, 1999 (9)      Abdomen radiograph: free intraperitoneal and
                              retroperitoneal air

Kim et al, 2000 (14)        Abdomen radiograph: free air

Baron et al, 2000 (10)      CT scan of abdomen: no contrast leak (b)

Roses et al, 2000 (11)      GI radiograph series: no contrast leak (b)

Shimamoto et al, 2000 (12)  Chest radiograph: linear air along the right
                              cardiac border
                            Gastrografin study: no contrast leak (b)

Charabaty-Pishvaian and     Abdomen radiograph: free retroperitoneal air
  Al-Kawas (present study)  CT scan abdomen: no contrast leak (b)

Authors                          Outcome

Binmoeller et al, 1993 (8)  Discharge on Day 5

Wewalka et al, 1995 (13)    NA

Yoshikane et al, 1997 (15)  PO on Day 9
                            Discharge on Day 14

Kaneko et al, 1999 (9)      PO on Day 8

Kim et al, 2000 (14)        PO on Day 10
                            Discharge on Day 10

Baron et al, 2000 (10)      PO on Day 2
                            Discharge on Day 3

Roses et al, 2000 (11)      PO on Day 7
                            Discharge on Day 10

Shimamoto et al, 2000 (12)  PO on Day 17

Charabaty-Pishvaian and     PO on Day 3
  Al-Kawas (present study)  Discharge on Day 4

(a) PO, oral intake: GI, gastrointestinal; CT, computed tomographic;
LES, lower esophageal sphincter: NA, data not available.
(b) After endoclipping.

Accepted June 27, 2003.

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9702-0190

References

(1.) Chaudhary A, Aranya RC. Surgery in perforation after endoscopic sphincterotomy: Sooner, later or not at all? Ann R Coll Surg Engl 1996;78:206-208.

(2.) Bell RC, Van Stiegmann G, Goff J, et al. Decision for surgical management of perforation following endoscopic sphincterotomy. Am Surg 1991;57:237-240.

(3.) Stapfer M, Selby RR, Stain SC, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000;232:191-198.

(4.) Chung RS, Sivak MV, Ferguson DR. Surgical decisions in the management of duodenal perforation complicating endoscopic sphincterotomy. Am J Surg 1993;165:700-703.

(5.) Howard TJ, Tan T, Lehman GA, et al. Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 1999;126:658-665.

(6.) Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: An attempt at consensus. Gastrointest Endosc 1991;37:383-393.

(7.) Hayashi T, Yonezawa M, Kuwabara T, et al. The study on staunch clip for the treatment by endoscopy. Gastrointest Endosc 1975;17:92-101.

(8.) Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993;39:172-174.

(9.) Kaneko T, Akamatsu T, Shimodaira K, et al. Nonsurgical treatment of duodenal perforation by endoscopic repair using a clipping device. Gastrointest Endosc 1999;50:410-413.

(10.) Baron TH, Gostout CJ, Herman L. Hemoclip repair of a sphincterotomy-induced duodenal perforation. Gastrointest Endosc 2000;52:566-568.

(11.) Roses LL, Ramirez AG, Seco AL, et al. Clip closure of a duodenal perforation secondary to a biliary stent. Gastrointest Endosc 2000;51:487-489.

(12.) Shimamoto C, Hirata I, Umegaki E, et al. Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc 2000;51:736-739.

(13.) Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608-611.

(14.) Kim HS, Lee DK, Jeong YS, et al. Successful endoscopic management of a perforated gastric dysplastic lesion after endoscopic mucosal resection. Gastrointest Endosc 2000;51:613-615.

(15.) Yoshikane H, Hidano H, Sakakibara A, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997;46:464-466.

(16.) Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus. Surg Endosc 1988;2:13-17.

(17.) Devereaux CE, Binmoeller KF. Endoclip: Closing the surgical gap. Gastrointest Endosc 1999;50:440-442 (editorial).

RELATED ARTICLE: Case Report

A 69-year-old man had a history of a large duodenal adenoma removed in 1997. He was lost to follow-up for several years before returning for surveillance esophagogastroduodenoscopy. At this time, a sessile polyp, 40 mm in diameter, was found in the duodenum approximately 5 cm distal to the papilla (Fig. 1A). Using a standard sclerotherapy needle, the base of the polyp was injected and lifted with 3 ml of a mixture of normal saline and 1:10,000 epinephrine. A standard polypectomy snare was positioned around the base of the polyp. Using coagulation current and a setting of 3 on a Valley Lab SSE unit (Valley Lab, Boulder, CO), the polyp was resected and retrieved in toto using a Roth basket (United States Endoscopy Group, Inc., Mentor, OH). Immediately after polyp retrieval, a 5-mm round area of perforation was noted at the polypectomy site (Fig. 1B). The decision was made immediately to proceed with endoscopic repair of the duodenal perforation.

A disposable endoclipping device (QuickClip HX-200U-135; Olympus America, Inc., Melville, NY) was passed through the working channel of the endoscope (Pentax Precision Instruments, Orangeburg, NY) and applied to the area of perforation. A total of five endoclips were used to approximate the margins of the defect such that the perforation was fully sealed (Fig. 2).

After the procedure, the patient complained of diffuse abdominal pain. On physical examination, he was afebrile, with a normal heart rate and blood pressure. His abdomen was diffusely tender but was soft, nondistended, and without rebound tenderness. There was no subcutaneous emphysema, and abdominal bowel sounds were normal.

A plain, upright film of the abdomen revealed free retroperitoneal air under the liver and tracking down the right psoas muscle. A computed tomographic scan of the abdomen with oral contrast showed evidence of retroperitoneal air but no leakage of contrast material (Fig. 3). The patient was made NPO and started on IV antibiotics (levofloxacin and metronidazole). Surgical consultation was obtained and agreed with the outlined conservative management. The patient had a benign clinical course: the abdominal pain resolved the next day without analgesics, and the patient did not develop any fever, peritoneal signs, or leukocytosis. A clear liquid diet was started on Day 3 of the hospital stay and was advanced to a full diet the same night. The patient was discharged on Day 4 on oral levofloxacin for 5 days. Pathologic examination of the polyp revealed a tubular adenoma without dysplasia. The base of the stalk showed no evidence of involvement by the adenoma.

Aline Charabaty-Pishvaian, MD, and Firas Al-Kawas, MD

From the Division of Gastroenterology, Georgetown University Hospital, Washington, DC.

Reprint requests to Firas Al-Kawas, MD, Division of Gastroenterology, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007. Email: [e-mail]