Post written by Haruka Okada, MD, from the Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.

We reported a case in which simultaneous bile duct injury with massive bile leakage and duodenal retroperitoneal perforation during endoscopic submucosal dissection (ESD) for a large periampullary adenoma were successfully managed by placing a self-expandable metallic stent and naso-pancreatic drain.

Although duodenal ESD is a challenging procedure, its frequency is gradually increasing because of recent advances in endoscopic technology and development of devices.

The first important aspect of this case is that, even in the presence of bile duct injury and retroperitoneal perforation, complete isolation of pancreatic fluid and the perforation site with a naso-pancreatic drain and compression of the perforated site with self-expandable metallic stents may provide a favorable outcome.

Notably, despite continuous bile exposure to the injury site, the clinical course of this case was quite good, suggesting that drainage of the pancreatic juice may be particularly essential.

The second important point could be a warning to emphasize the need for meticulous consideration when resecting lesions, especially those located on the oral side of the papilla, because of the risk of bile duct injury from the lateral side.

The anatomical characteristics of the duodenum, such as the fixed position to the retroperitoneum, tortuous lumen, thin duodenal wall, and rich Brunner’s glands in the submucosa, make ESD difficult. The case reports are still limited compared with those about other organs such as the esophagus, stomach, and colon.

This case report will help you learn about the rare adverse events of duodenal ESD and appropriate and minimally invasive treatments for them. Even in the presence of severe adverse events such as bile duct injury and retroperitoneal perforation, patients can recover without surgical intervention.

Workup endoscopic images. A, Large, flat-elevated tumor located in the second portion at the oral side of the papilla. B, Chromoendoscopy with indigo carmine emphasizes elevated nodules on the tumor.

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