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A 68-year-old man with a history of hypertension and chronic cholecystitis underwent a complicated open cholecystectomy with intraoperative cholangiogram, which demonstrated choledocholithiasis and suspected bile leak. A Jackson-Pratt (JP) drain was placed, and the patient presented 3 weeks postoperatively for ERCP with stone extraction and drain removal (Video 1, available online at www.VideoGIE.org).
ERCP with an occlusion cholangiogram demonstrated multiple stones in the distal common bile duct and diffuse dilation of the duct up to 14 mm without evidence of extravasation of contrast material. A sphincterotomy was performed, and the biliary tree was swept with a 15-mm balloon, with complete clearance of the stones. During withdrawal of the JP drain, it was inadvertently severed and immediately retracted into the peritoneum (Fig. 1). Upon recognition, intravenous levofloxacin was administered, and the ERCP endoscope was exchanged for a linear EUS endoscope.
Figure 1Fluoroscopic view of a severed Jackson-Pratt drain retracted into peritoneum.
The JP drain was seen in the peritoneum using US. To create a tract that would allow removal of the drain by natural orifice transluminal endoscopic surgery, it was punctured under EUS guidance, and contrast material was injected into the drain to confirm positioning. A 0.025-inch by 450-cm angled guidewire was passed along the drain tract into the peritoneum (Fig. 2). Over the wire, a through-the-scope 10-11-12-mm pyloric balloon dilator was advanced through the duodenal wall and dilated under fluoroscopic guidance. The linear EUS endoscope was then withdrawn over the wire and exchanged for a forward-viewing adult upper endoscope. The endoscope was passed across the duodenal wall to allow direct visualization of the drain in the peritoneum. A rat-toothed forceps was then used to grasp the drain (Fig. 3), followed by removal of the drain from the peritoneum.
Figure 2EUS view of a guidewire passed along the drain tract into the peritoneum.
The ensuing defect in the duodenal wall was evaluated and thought to be amenable to endoscopic closure. An over-the-scope clip was loaded onto the endoscope, and the defect was suctioned into the cap before deployment of the clip. The clip was well positioned over the defect without evidence of duodenal leak (Fig. 4), and the patient’s abdomen was soft at the end of the procedure. The patient remained an outpatient and experienced no adverse events. He was discharged back to his long-term care facility after the procedure, and 1 year after the procedure, he has required no further interventions.
Figure 4Endoscopic view of an over-the-scope clip used to close the duodenal defect.
A contingency plan in the case of procedure-related adverse events is critical to the practice of endoscopy. Therapeutic EUS with or without peritonoscopy may be used in the retrieval of foreign objects. Defect closure and prompt initiation of intravenous antibiotics is essential to reduce the risk of infection.
Disclosure
Dr James receives research and training support in part by a grant from the National Institutes of Health (T32DK007634). Dr Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America.
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