Large type I post-ERCP perforation closed immediately through the duodenoscope with through-the-scope endoclips.

Duodenal perforation as complication of endoscopic retrograde cholangiopancreatography (ERCP) is a rare but serious secondary event with an incidence of 0.6%– 0.99% [1]. The most dangerous type of perforation is that categorized as type I in the classification by Stapfer et al. [2] and usually located in the lateral or medial duodenumwall. This is associated with high mortality rates (28%–47%) [3] and requires surgical intervention in over 86% of cases [4]. Recently, the European Society of Gastrointestinal Endoscopy (ESGE) has recommended immediate closure during endoscopy, which is usually successful in 22% of attempts [5]. Case reports describe many differentmethods, but themost frequently used technique is application of endoclips with forward-viewing endoscopes [6]. Other techniques include the use of overthe-scope clips (OTSCs; Ovesco, Tübingen, Germany, and Aponos, Kingston, New Hampshire, USA) as well as glues, meshes, biologic or synthetic plugs, and endoloop plus clipping. However, with all these methods it is necessary to replace the lateral-viewing endoscope with a forwardviewing one. The patient was an 86-year-old man with multiple co-morbidities including metastatic prostate cancer of the lung and the liver hilum, the latter having been treated with a plastic biliary stent 2 months previously. The patient was not a surgical candidate and presented for stent exchange, with a planned replacement of the plastic stent by a self-expandablemetal stent (SEMS). Unfortunately, during the endoscopy a perforation of 13mm diameter was clearly visible in the lateral wall of the duodenum (●" Fig.1a,●" Fig.1b). Immediately after visual identification of the perforation, we thoroughly aspirated the duodenal contents. Without exchangFig.3 Enterography with Gastrografin contrast showed no leak. Fig.2 The perforation was closed by means of four through-the-scope (TTS) endoclips, placed through the lateral-viewing duodenoscope. Fig.1 a,b Duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) in an 86-year-old patient with prostate cancer metastases to the liver hilum and lung. Cases and Techniques Library (CTL) E86