PTH-073 Successful endoscopic closure of DU perforation using OTSC in a frail patient unsuitable for surgery

IntroductionEndoscopic closure devices continue to be used successfully to close iatrogenic perforations within the GI tract. However, only a handful of cases describe successful closure of a spontaneous duodenal perforation. We present the first UK case to demonstrate successful endoscopic closure of perforated duodenal ulcer using over-the-scope clips in a patient unfit for surgery.MethodsThe case involved an 85-year-old bedbound female patient with COPD, mild dementia, hypertension, hypercholesterolaemia and three previous cardiac arrests. She attended hospital unwell after passing melaena and experiencing abdominal pain. Her abdomen was markedly tender and subsequent CT imaging confirmed a full thickness perforation at the duodenal bulb. Due to her multiple medical comorbidities she was not an operative candidate and the perforation would be managed conservatively with bowel rest and broad spectrum antibiotics. The patient was referred to the gastroenterology team who considered high risk endoscopic closure after a discussion with the patient’s family. After transfusion and fluid resuscitation, gastroscopy with CO2 insufflation was performed under conscious sedation (1 mg midazolam and 50 mcg fentanyl). A deep ulcer with evidence of recent bleeding was identified in the duodenal bulb, through which the full thickness perforation site could be observed. Two OTSC clips were applied successfully to close the defect.ResultsFollowing OTSC clip deployment the patient was kept nil by mouth. Seventy-two hours post endotherapy an interval CT identified a reduced volume of pneumoperitoneum with no extraluminal leakage of contrast confirming successful closure. The patient was then allowed to eat and drink normally. A repeat gastroscopy on day seven demonstrated full closure of the duodenal perforation. The patient was commenced on H. pylori eradication and discharged eleven days after initial presentation.ConclusionsSurgical repair remains the gold standard treatment for the repair of a spontaneous enteral perforations. Candidacy for surgical repair does however require candidacy for general anaesthesia which is often not the case amongst our increasingly aging and comorbid population. This is one of a handful of cases worldwide and indeed the first ever reported case in the UK of a spontaneous duodenal perforation being successfully repaired using an endoscopic closure device. The key determinant for success in this case were the use of CO2 insufflation and the