Post written by Andrew Canakis, DO, from the Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.

In this video, we demonstrate full-thickness endoscopic closure of an acute duodenal perforation using an over-the-scope suturing system.

A 70-year-old patient with a history of abdominal surgeries and concerns for a duodenal perforation was transferred to our center. He initially presented with 5 days of progressive abdominal pain, fever, nausea, vomiting, and inability to tolerate oral intake.

A CT scan of the abdomen revealed free air and fluid near the duodenum concerning for duodenal perforation secondary to nonsteroidal anti-inflammatory drug use. He was started on broad-spectrum antibiotics. A percutaneous drain was placed, and for further care, he was transferred to our center, where he was deemed a poor surgical candidate.

Endoscopy demonstrated a 1-cm duodenal perforation. Given its size and location, a full-thickness suturing device (OverStitch Endoscopic Suturing System; Apollo, Austin, Tex, USA) was used to place a single running suture to close the perforation. Distal to proximal running sutures were taken. This was accomplished with an out-to-in bite distally into the defect, then bringing that to the contralateral wall with an in-to-out bite.

Closure was confirmed with contrast injection, and a nasojejunal tube was placed for enteral nutrition. The patient’s abdominal pain improved. The following day, an upper GI series showed no leak, and he was started on clear liquids.

Repeat upper GI series on day 6 and CT scan on day 7 showed no leak. Yet, a tube check noted a small persistent connection to the duodenum for which a second endoscopy with another full-thickness suture was successfully performed.

To provide the most robust closure option, we chose the full-thickness suturing device over other modalities (ie, through-the-scope clips, over-the-scope clips [OTSCs], or a through-the-scope helix tacking system). If a recurrent leak develops around an OTSC, it can be more difficult to fix and require removal of the OTSC, which can sometimes be challenging.

In a high-risk surgical patient, endoscopic full-thickness suturing can be used to repair even a perforated ulcer with peritoneal contamination along with an external drain placement. Percutaneous drainage was important and effective in draining the leaked contents and perhaps in reducing duodenal edema from the bilio-pancreatic juices, allowing for easier suture closure.

Checking on the integrity of the sutures the next day and 5 to 7 days after closure is crucial, given the risk of dehiscence because of the contaminated and possibly unhealthy tissue. This can be readdressed with suturing in the correct setting.

Of note, the procedure was performed with the patient under general anesthesia, allowing manipulation of the double-channel therapeutic scope more comfortably in a long scope position, as is sometimes needed in the duodenum.

Full-thickness suturing of the perforation.

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