P0666 - Covered Esophageal Stent for Duodenal Perforation: A Review of Two Cases

Award: Presidential Poster Award

Award: Presidential Poster Award

Meghana Doniparthi, MD, Sufyan AbdulMujeeb, DO, Assad Munis, DO, Natasha Shah, MD, Kenneth Chi, MD
Advocate Lutheran General Hospital, Park Ridge, IL

Introduction: Gastrointestinal perforations carry significant morbidity and mortality in hospitalized patients. While esophageal perforations can be managed endoscopically, surgical repair is the mainstay of treatment for gastric or duodenal perforations. We present two cases of duodenal perforations successfully managed with endoscopic placement of a fully covered stent as both a first-line intervention and second-line treatment after failure of surgical repair.

Case Description/Methods: A 56 year old male underwent exploratory laparotomy and was found to have a perforated duodenal ulcer. Two attempts at Graham patch repair were made; however, follow up contrast imaging demonstrated persistent contrast extravasation. Using both direct visualization and fluoroscopy, he underwent endoscopic placement of a fully covered 23mm x 12cm esophageal stent across the area of perforation in the first portion of the duodenum (Fig 1A, 1B, 1C). An “over-the-scope” clip (OTSC) was used to secure the stent in place. Repeat oral contrast radiograph three days later did not show extravasation.



A 77 year old male was taken to the OR for planned cholecystectomy and was found to have necrotizing cholecystitis and purulent peritonitis. Upper GI contrast study confirmed proximal duodenal perforation. He underwent EGD with discovery of a 2 cm diverticulum in the duodenal bulb as the most likely source of perforation. Using similar technique, a fully covered 22 mm x 10 cm esophageal stent was placed across the duodenal perforation. An OTSC was placed to secure the stent (Fig 1D).



Both patients recovered well and had their stents removed 2 months post discharge (Fig 1E).



Discussion: Off-label use of covered stents in duodenal perforations is an emerging salvage technique in patients who have failed initial surgical repair or who require a minimally invasive approach. Using simultaneous fluoroscopy and direct visualization for stent deployment ensures accurate placement. Covered stents are at risk for migration, and previous reports have described use of a partially covered stent to decrease this risk. We successfully mitigated this using a device to secure the fully covered stent. Use of this technique may be limited to perforations in the duodenal bulb given the short length of deployment catheter. As shown in these two cases, endoscopic stent placement may be an attractive alternative to duodenal perforations and may become standard of care in the future.


Figure: Figure 1. A: Using a side-by-side technique, the fully covered stent was deployed under direct visualization. B: The scope is able to traverse the stent placement and visualize duodenal perforation. C: Fluoroscopic image of the scope traversing the first and second portions of the duodenum through the deployed stent on index endoscopy. D: An over the scope clip is used to secure the proximal end of the stent in order to prevent migration. E: The stent was removed after two months, and a well-healing perforation site was identified.


Disclosures:
Meghana Doniparthi indicated no relevant financial relationships.
Sufyan AbdulMujeeb indicated no relevant financial relationships.
Assad Munis indicated no relevant financial relationships.
Natasha Shah indicated no relevant financial relationships.
Kenneth Chi indicated no relevant financial relationships.


Meghana Doniparthi, MD, Sufyan AbdulMujeeb, DO, Assad Munis, DO, Natasha Shah, MD, Kenneth Chi, MD. P0666 - Covered Esophageal Stent for Duodenal Perforation: A Review of Two Cases, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.