Recently, duodenal endoscopic resection (ER) including endoscopic mucosal resection and endoscopic submucosal dissection (ESD) is one of the main methods for management of superficial lesions, which avoids the high invasive pancreaticoduodenectomy. Despite ER is micro-invasive, complications like delayed perforation could occur, especially in ESD cases.[1–3] Previous studies suggested that complete closure of the mucosal defect helps to prevent delayed perforation,[1,4] however, it could be technically impossible in some cases with large mucosal defect. Partial closure helps to narrow the defect, but without improvement in reducing delayed complications. Herein, we reported a case of delayed perforation of ESD in the second part of duodenum, in which endoscopic partial closure followed by adequate drainage was successful for wound healing. This technique may also serve as an alternative for prevention of delayed perforation in selected patients.
2 Case presentation
Our case report is a retrospective and descriptive analysis. Informed written consent was obtained from the patient for publication of this case report and accompanying images.
A 56-year-old woman underwent ESD for management of a large laterally spreading tumor in the opposite duodenal wall of papilla, that involved about 3 quarters of the circumference (Fig. 1A). With the help of magnetic bead-traction (Fig. 1B), a method developed to facilitate ESD,[5,6] the procedure went smoothly and en bloc resection of the large tumor was achieved finally (Fig. 1C). Because of the difficulty in closing the large mucosal defect and no obvious damage to muscularis during the procedure, the mucosal defect was left without closure (Fig. 1D). Pathologic results demonstrated that the tumor of intramucosal carcinoma was resected curatively.
Unfortunately, the patient complained significant abdominal pain and fever (38.9°C) at postoperative day 1. Physical examination showed entire abdominal tender with guarding and rebound tenderness. Liver dullness was also absent. Laboratory tests revealed elevated white blood cell counts (11.88 × 10^9/L, normal value: 4-10 × 10^9/L) and c-creative protein level (53 g/L, normal value: <5 g/L). Emergent abdominal computed tomography (CT) confirmed the presence of abdominal inflammation and duodenal perforation in the anterior wall (Fig. 2). Thus, a delayed perforation of duodenal ESD was diagnosed.
Considering the high invasive nature of surgery, the patient preferred to receive endoscopic repair and conservative treatments. Underwritten informed consent of patient and her families, we performed endoscopic intervention for her. A minor perforation was found in the mucosal defect of ESD (Fig. 3A). Purse-string suture with 2 Nylon rings and several endoclips was initially used to close the perforation and reduce the mucosal defect (Fig. 3B). To minimize the digestion of digestive juices to the partially closed wound, we performed a percutaneous endoscopic gastrostomy (PEG) (Fig. 3C) for gastric decompression and drainage (by connecting a negative pressure drainage bag), and proximal duodenal drainage (by inserting a jejunal tube through the PEG to the proximal end of the wound); we also placed a nasointestinal decompression tube (the commonly used nasobiliary tube) in the distal end of the wound for drainage of regurgitated digestive juices (Fig. 3D). Intravenous antibiotics, proton pump inhibitor, somatostatin, and parenteral nutrition were given following the procedure.
No further symptoms were noted after 5 days. Upper gastrointestinal series was performed at 7th day, showing no leakage of contrast agent (Fig. 4A). Upper endoscopy was also performed to send the jejunal tube to distal duodenum for enteral nutrition (Fig. 4B). The patient began to eat at 15th day, and was discharged at postoperative day 23. Recheck upper endoscopies at postoperative month 2 and 4 confirmed complete healing of the wound (Fig. 4C/D). There were no obvious duodenal stricture or tumor recurrence.
Delayed perforation of duodenal ESD was reported to be up to 14.3%, much higher than that of colorectal ESD (0.4%–0.7%). One of the possible mechanisms of delayed duodenal perforation was the exposure of iatrogenic ulcer to the digestive juice[1,4,7]; this may also explain why higher incidence of delayed perforation was noted in distal duodenum. Peritonitis, retroperitonitis or retroperitoneal abscess can be presented. Delayed perforation of duodenal ESD is a clinical emergency, immediate CT for full assessment is needed. Sometimes, high-invasive surgical intervention is required.[2,8] Notably, with or without surgery, longer hospital stay is frequently needed once delayed perforation of duodenal ESD occurred.[2,8]
It was reported that prophylactic closure of the mucosal defect after ESD could prevent delayed complications.[1,4] Although many closure techniques have been reported, like through-the-scope clip, over-the-scope clip system, overstitch system, purse-string suturing, string clip suturing, and band ligation, complete closure of the wound still remains a problem in lesions with larger occupied circumference. In the present case, the lesion involved more than half of the circumference, thus complete closure of the wound was technically difficult. Since no obvious muscularis injury or perforation was noted, we left the mucosal defect without attempt of closure. Unfortunately, delayed perforation was complicated, which could be attributed to the digestion of the muscularis by direct exposure to digestive juices in the duodenum. Partial closure of the mucosal defect is usually used to prevent delayed complications in other parts of gastrointestinal tract, however, the recent study did not support its role in duodenal ESD. We previously reported the use of double PEGs for treating a refractory duodenal fistula, in which adequate drainage of digestive juices was achieved, reducing the digestion to surrounding tissue and allowing spontaneous healing of the fistula. Therefore, we carried out effective drainage (gastric drainage, proximal drainage of the wound, and distal drainage of the wound) after partial closure of the wound for the delayed perforation. The hospital stay of this patient (23 days) was significantly reduced compared with former studies (28–81 days after conservative management and 32–41 days after surgery).[2,8] Such good outcome of our case revealed that partial closure with adequate drainage can be used for management of delayed perforation of duodenal ESD. This method may also serve as an alternative for preventing delayed perforation when complete closure of the wound is technically difficult or impossible.
In conclusion, endoscopic partial closure followed by adequate drainage can be used to treat delayed perforation after large duodenal ESD. It may also serve as an effective method for prevention of delayed perforation in select patients.
Supervision: Bing Hu.
Writing – original draft: Liansong Ye, Wenxiu Hou, Xianglei Yuan.
Writing – review and editing: Yiping Wang, Chuncheng Wu, Naveed Khan, Bing Hu.
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