Successful endoscopic closure of iatrogenic duodenal perforation with the new Padlock Clip.

Although duodenal perforations are rare [1], they represent one of the most critical complications of endoscopic ultrasound (EUS) and may be fatal in elderly patients. Following the introduction of endoscopic clips, stents, and over-thescope systems into clinical practice, endoscopic management of perforations has became the first therapeutic option [2, 3]. We present the case of a 62-year-old man with jaundice, who was referred to the Digestive Endoscopy Unit of Humanitas Research Hospital (Rozzano, Italy) to undergo EUS-guided fine-needle aspiration of a solid lesion in the pancreatic head (▶Fig. 1). The EUS was performed using a linear echoendoscope (GF-UCT140; Olympus Optical Co., Tokyo, Japan), CO2 insufflation, and with the patient under deep sedation with propofol. During scope withdrawal through the duodenum, we observed a type-1 [4], full-thickness defect, of 13mm in diameter, at the upper duodenal knee (▶Fig. 2). A stiff guidewire was placed in the duodenum to help expose the defect. A twin grasper (Ovesco Endoscopy AG, Tübingen, Germany) was used to approximate the mucosal edges of the perforation. Then, a gastroscope loaded with the new Padlock Clip (Aponos Medical Co., King-