Surgery avoided by the use of over-the-scope clips for severe duodenal complications associated with endoscopic mucosal resection.

During endoscopic treatment for duodenal neoplasm, hazardous complications such as perforation and bleeding sometimes occur owing to the anatomical characteristics of the duodenum [1–3]. Although surgical repair has been traditionally required for these complications, the procedure is invasive and complicated [4]. A currently available overthe-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) has provided excellent outcomes for gastrointestinal refractory bleeding and full-thickness defects [5]. Here, we describe a notable case in which iatrogenic duodenal complications could be managed with OTSCs. A 56-year-old man presented with a duodenal adenoma that showed a reddish and flat elevated lesion, approximately 10mm in diameter, located in the posterior wall of the second duodenal portion (▶Fig. 1). After submucosal injection, cap-assisted endoscopic mucosal resection (EMR) was performed under carbon dioxide insufflation. A large full-thickness perforation, 20mm in diameter, occurred (▶Fig. 2 a), and spurting arterial bleeding was seen (▶Fig. 2 b). The bleeding was accompanied by hemorrhagic shock and was immediately controlled using hemostatic forceps (Coagrasper; Olympus, Tokyo, Japan). OTSCs were then applied to close the defect at the perforation site, after obtaining informed consent. Grasping forceps (Twingrasper; Ovesco Endoscopy) were used to approximate the edges of the large defect. The defect was mostly closed by one OTSC (t type, 9mm), and the remaining defect was closed by an additional OTSC using simple suction (▶Fig. 3, ▶Video1). A radiographic examination 5 days later confirmed no leakage at the perforation site (▶Fig. 4). The patient was discharged without additional interventions 19 days later. A histological examination revealed E-Videos