*Gastroenterology and Endoscopy Service, University of Parma, Parma Italy
†Department of Gastroenterology, Great Ormond Street Hospital, London, UK
‡Emergency Surgery, University of Parma, Parma, Italy.
Address correspondence and reprint requests to Prof Gian Luigi de’ Angelis, MD, Gastroenterology and Endoscopy Service, University of Parma, via Gramsci 14, 43100 Parma, Italy (e-mail: firstname.lastname@example.org).
Received 24 November, 2011
Accepted 9 December, 2011
The authors report no conflicts of interest.
Duodenal injuries represent a small but formidable, challenging group of pediatric trauma. Due to its protected retroperitoneal location, injuries to the duodenum are relatively uncommon in children, accounting for 3% to 5% of all of the blunt abdominal injuries (1,2); however, due to their rarity and delayed diagnosis, duodenal trauma remains an important source of morbidity and mortality (3). Although over the last decades, management of blunt duodenal trauma has shifted from operative surgery to selective nonoperative surgery; the former is still considered the cornerstone for primary repair of low-grade duodenal injury to reduce the length of hospitalization, intensive care unit time, need for parenteral nutrition, and overall complication rates (4,5). However, endoscopic treatment through the use of operative accessories could provide an excellent alternative option to close limited wall defects without the need for surgery. Herein we describe the use of a clipping device present to close a post-traumatic duodenal perforation.
A 15-year-old-boy was admitted to the pediatric emergency department of our university hospital after a motorbike collision. The child was extensively bruised around and below the umbilicus and manifested at physical examination lower abdominal tenderness with significant lower abdominal pain. He was hemodynamically stable. Extraluminal oral contrast, discontinuity and localized thickness of ileal wall with adjacent free air, and free intraperitoneal fluid were detected by contrast-enhanced computed tomography scan. No injury to any other solid organs was observed. He was referred to the surgeons and was operated within 3 hours after the injury. Under general anesthesia and broad-spectrum antibiotic coverage, laparotomic exploration of the gastrointestinal (GI) tract confirmed the presence of ileal subserosal hemorrhages, and subsequently a segmental resection was performed. Moreover, a sigmoid perforation was also identified and primarily repaired. Postoperatively, the child remained in the intensive care unit overnight and a parenteral nutrition was started.
After 2 days, he started presenting a biliary leak (approximately 1200 mL/day) from surgical abdominal drainage. A second computed tomography scan failed to show any abnormalities. Therefore, an upper GI endoscopy, performed using a pediatric videoendoscope (Olympus GIF160 [Olympus, Tokyo, Japan] ∅ 9.8 mm, biopsy channel ∅ 2.0 mm) during propofol sedation, revealed a 3-cm perforation in the posterior wall of second portion of duodenum. With the patient clinically worsening, octreotide was started at full dose to suppress the pancreatic secretion. After 7 days, without any clinical improvement, a second GI upper endoscopy was performed, which confirmed the duodenal perforation (Fig. 1A). The endoscope was inserted into the perforation for approximately 1 cm, and the retroperitoneal cavity did not show any signs of infection, pus collections, or necrotic area. By using a standard operative endoscopic catheter, 3 fibrin glue injections (Tissucol; Baxter Healthcare Corp, Deerfield, IL) were performed: the first (10 mL) into the retroperitoneal cavity close to the external duodenal wall, the second (5 mL) into the perforation, and the third into a large lateral parietal recess. Finally, by using a disposable endoclipping device (Boston Scientific Corp, Natick, MA), 4 clips (Resolution Clip; Boston Scientific Corp) were deployed on the margins of the perforation (Fig. 1B), without a complete closure of the wall defect to drain a potential abscess.
After the endoscopic procedure, no biliary leak from the abdominal drainage was observed. The child was treated with broad-spectrum intravenous antibiotics and remained on parenteral nutrition. An endoscopy performed 7 days later still showed the presence of a small area of perforation without any sign of infection. Therefore, another clip was deployed with the complete apposition of the wound margins. Because the patient recovered well without complaining of any abdominal symptoms, he was started on oral feeding after 4 days and discharge home after 7 days. An upper endoscopy was performed 1 month after discharge showing the presence of 3 clips still present in the duodenal wall and the complete wound healing.
Duodenal injuries following blunt abdominal trauma are usually related to motor vehicle accidents. Despite their rarity in pediatric age, they are associated with high morbidity and mortality (1–3). The pathophysiology of organ rupture is still a matter of debate; however, the direct compression with tearing between 2 opposing surfaces such as the abdominal wall and spine is considered the leading mechanism of intestinal injury (6). Obviously, fixed areas of the bowel such as the duodenum are at increased risk. A surgical approach still remains the mainstay of management of duodenal trauma secondary to nonpenetrating injury, and present recommendations advocate primary repair for low-grade injury and more complex procedures, such as pyloric exclusion and duodenal diversion, for severe injuries (3–5).
Endoscopic clips were first introduced in 1975 by Hayashi et al (7) for treating GI bleeding; however, over the last years, endoscopic clip placement has been successfully used for a wide variety of indications including closure of GI fistula, anastomotic leak, and iatrogenic perforation throughout the GI tract (8). For instance, numerous reports describe the possibility of nonsurgical treatment for perforation of the upper GI tract when no peritonitis is present (8). To our knowledge, the use of a clipping device in combination with fibrin glue injections for closure of a traumatic duodenal perforation, as in our case, has not been previously described. In our study, the clinical worsening of the patient after the first surgery was a contraindication for re-surgery. On the contrary, the lack of infection signs and easy endoscopic access were favorable conditions for positioning endoclips and injecting fibrin glue. Obviously, the major risk of this procedure was the therapeutic failure. Our patient was receiving oral feeding after 4 days and was discharged after 7 days.
Although large patient series are required, based on our experience of using endoclips and fibrin glue in the closure of large duodenal perforation, this procedure should be explored as an option in the management of critically ill patients with duodenal blunt trauma; however, technical mastery of the deployment of endoclips is crucial for successful closure of surgical gaps.
1. Ivatury RR, Nassoura ZE, Simon RJ, et al. Complex duodenal injuries. Surg Clin North Am 1996; 76:797–812.
2. Clendenon JN, Meyers RL, Nance ML, et al. Management of duodenal injuries in children. J Pediatr Surg 2004; 39:964–968.
3. Degiannis E, Boffard K. Duodenal injuries. Br J Surg 2000; 87:1473–1479.
4. Besselink MGH, Berende NCAS, Preshaw RM, et al. Non-operative treatment of duodenal perforation secondary to blunt abdominal trauma. Int J Care Injured 2001; 32:513–515.
5. Ladd AP, West KW, Rouse TM, et al. Surgical management of duodenal injuries in children. Surgery 2002; 132:748–752.
6. Williams RD, Sargent FT. The mechanism of intestinal injury in trauma. J Trauma 1963; 31:735–748.
7. Hayashi I, Yonezawa TM, Kuwabara T, et al. The study on staunch clip for the treatment by endoscopy. Gastoenterol Endoscopy 1975; 17:92–101.
8. Raju GS, Gajula L. Endoclips for GI endoscopy. Gastrointest Endosc 2004; 59:267–279.