Management of an iatrogenic duodenal perforation with a helical tack system in a patient with pancreatic cancer complicated by gastric outlet obstruction

Although endoscopic procedures are safe, they carry a risk of perforation, which can manifest severe adverse events for patients if not managed expediently. Endoscopic methods of closure include clips, injectable agents, and suturing devices.^, Occasionally, perforations occur in difficult locations. Recently, a through-the-scope tacking system, X-tack Endoscopic HeliX Tacking System 160 cm (HTS) (Apollo Endosurgery Inc, Austin, Tex, USA), has been made available for mucosal defect closure, providing endoscopists with another tool to manage adverse events.^, There is emerging evidence for the use of the X-tack system in accomplishing closure of full-thickness defects. Here, we demonstrate the use of the HTS for management of a duodenal perforation during endosonographic evaluation of a pancreatic mass. The repair using the HTS was durable and allowed for EUS-guided choledochoduodenostomy (EUS-CD) to be performed.

A 58-year-old man without significant medical history presented with jaundice. Cross-sectional imaging demonstrated a 3-cm pancreatic head mass causing biliary dilation (Fig. 1). EUS revealed a gastric outlet obstruction (GOO) because of severe extrinsic duodenal stenosis from the mass. A fine-needle biopsy was diagnostic for pancreatic ductal adenocarcinoma; however, during the examination, an iatrogenic tear proximal to the GOO occurred. Because the perforation occurred close to the duodenal stenosis in the region of the duodenal sweep, the endoscopist decided that optimal defect closure would be achieved using the HTS. Four tacks connected by a 3.0 polypropylene suture were placed in a Z pattern across the defect (Fig. 2). Contrast was subsequently injected, which confirmed defect closure as there was no evidence of a persistent leak (Fig. 3). To reinforce closure, an 18- × 140-mm esophageal covered metal stent was placed across the stenosis and sutured in place with an over-the-scope suturing device. Given the events, ERCP and biliary decompression were deferred to a future endoscopy. At completion of the procedure, a GI fluoroscopic series demonstrated no extravasation of contrast. Closure was also confirmed on subsequent upper GI series and a CT scan of the abdomen (Figs. 4 and 5). Total procedural time was 2 hours. The patient was maintained at nothing-by-mouth with a nasogastric tube to intermittent suction for 5 days, and he then resumed a clear liquid diet and advanced to a mechanical soft diet the following day.

Endoscopy was repeated 2 weeks later. The tack system was identified and no signs of perforation were observed. The previously placed duodenal stent was removed, and a contrast examination again demonstrated no evidence of a perforation. Because the duodenal stenosis was still not traversable, ERCP was deferred. To achieve biliary decompression, an EUS-CD was performed using a 6- × 8-mm lumen-apposing metal stent (AXIOS; Boston Scientific, Marlborough, Mass, USA) (Video 1, available online at www.giejournal.org).

The patient continued to tolerate a diet and had resolution of jaundice. Surgical oncology performed a robot-assisted gastrojejunostomy for definitive management of GOO. He has since received neoadjuvant chemotherapy and undergone a pancreaticoduodenectomy.

Prior studies have demonstrated the utility of the HTS for management of GI perforations.^, The HTS offers a substantial advantage in closure of challenging perforation sites that can be difficult to access with other devices. In our case video, the HTS was able to successfully manage an iatrogenic perforation, allowing us to also perform EUS-CD for management of biliary obstruction. The patient has had no further adverse events related to the perforation, demonstrating the durability of the closure achieved using the HTS. In the future, studies comparing the relative efficacy of the HTS to other devices will be needed to help endoscopists decide what situations may benefit from use of the HTS.