Endoscopic treatment of duodenal perforation following laparoscopic cholecystectomy.

complication of laparoscopic cholecys− tectomy and is associated with significant morbidity and mortality when diagnosis is delayed [1± 3]. Endoscopic closure has not been reported, although it has be− come an alternative for selected patients with postoperative gastrointestinal fistu− las in other locations [4]. We report the case of a 59−year−old male who underwent endoscopic retrograde cholangiopancreatography (ERCP) and la− paroscopic cholecystectomy for cholecys− titis with choledocholithiasis. He devel− oped pain and fever 2 days later. Ultraso− nography showed subhepatic fluid collec− tion so laparotomy was performed. Fluid collection on the gallbladder fossa was seen but no bile leakage was noticed. Subhepatic drainage was left in place, dis− charging up to 1200 mL/day. The patient was sent to our hospital 8 days later for assessment of the biliary tree. During ERCP a 12−mm perforation on the duode− nal bulb was found. The previously placed drainage tube was visible through the perforation (l" Fig. 1). Access with a gas− troscope to the abdominal cavity was gained through the perforation, which was limited to the right hypochondrium and blocked by the omentum (l" Vi− deo 1). Closure with endoclips was at− tempted but maximum opening of the endoclips did not embrace the edges of the perforation. Closure was then achiev− ed with a Vicryl mesh plug fixed to the borders of the perforation with endoclips (l" Video 2). A nasojejunal feeding probe and a nasogastric tube were left in place. Subhepatic drainage was not removed and intravenous antibiotics were admi− nistered. Over the following 72 hours, drainage output reduced to zero. On day 7, a liquid diet was started and, following the re− moval of the subhepatic drainage, the pa− tient was discharged.