Endoscopic retrograde cholangiography after endoscopic ultrasound-related duodenal perforation: keep calm, use over-the-scope clip, and carry on!

The over-the-scope clip (OTSC) is a useful tool recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation [1]. A retrospective study documented that OTSCs can avoid emergency surgical repair, allowing, in some cases, completion of the primary endoscopic procedure. As documented only once in the literature, its use could allow subsequent endoscopic procedures to be performed in the same session, owing to the endurance of the device during pneumatic and mechanical stress [2]. Here we report the video case of a 93-year-old woman who was referred to our unit to undergo biliopancreatic endoscopic ultrasound (GF-UCT 180; Olympus Co., Tokyo, Japan) for suspected choledocholithiasis, in the context of acute cholangitis; the patient was not a suitable candidate for surgery (cholecystectomy). After multiple biliary stones were detected in the common bile duct, a perforation was apparent in the wall of the superoanterior duodenal bulb. Because of the size of the perforation (about 15mm), an OTSC (11/6mm traumatic type; Ovesco Endoscopy GmbH, Tübingen, Germany) was applied using the suction technique to completely seal the defect [3]. As no further leakage was apparent following injection of contrast medium and the patient’s clinical conditionwas stable, endoscopic retrograde cholangiography (ERC; TJF-160 VR; Olympus Co.) with extraction of multiple biliary stones was performed in the same session (▶Video1). All procedures were performed with anesthesiological assistance, using carbon dioxide insufflation. ERC took about 45 minutes for complete biliary drainage (▶Fig. 1). The subsequent contrast medium (▶Fig. 2) and computed tomography scan with oral gastrographin confirmed the complete closure, despite the longlasting pneumatic and mechanical stress. No further complication occurred and the asymptomatic patient was discharged 1 week later. In conclusion, prompt endoscopic treatment using OTSCs represents an effective approach that can avoid later complications or surgical repair. Furthermore, the use of OTSCs can allow the completion of endoscopic procedure(s) in the same session, as the clips can endure prolonged pneumatic and mechanical stress.