Iatrogenic duodenal perforation during underwater ampullectomy: endoscopic repair using polyglycolic acid sheets.

Endoscopic resection is used to treat duodenal lesions [1]. However, the rate of perforation in the duodenum is relatively higher than that in other areas, and such perforation can be fatal [2]. Polyglycolic acid (PGA) sheets can be used to prevent delayed perforation after endoscopic submucosal dissection (ESD) in the duodenum [3], and to cover a delayed perforation after gastric ESD [4]. However, no reports have described the usefulness of PGA sheets for treating immediate iatrogenic duodenal perforation during underwater ampullectomy. A 45-year-old woman had a whitish, flat, laterally spreading 30-mm adenoma involving the ampulla of Vater (●" Fig.1). We decided to remove the lesion using underwater ampullectomy with a side-viewing duodenoscope [5]. We filled the duodenum with 0.9% saline to avoid hyponatremia, a major complication of the underwater technique, and performedpiecemeal resection with an electrosurgical snare (SnareMaster, SD-210U-25, 25mm; Olympus, Tokyo, Japan) (●" Fig.2). During the piecemeal resection, after removal of three tissue specimens, an approximately 10-mm perforation was observed on the posterior wall of the ampulla (●" Fig.3). After completion of the piecemeal resection, we filled the perforation with PGA sheets (Neoveil; Gunze Co., Kyoto, Japan), cut to approximately 20×10mm, and then sprayed fibringlue over the site (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) (●" Fig.4). We then placed nasoduodenal and nasobiliary drainage tubes andapancreatic duct stent. Computed tomography showed no free air or asFig.1 Esophagogastroduodenoscopy in a 45-year-old woman shows a whitish, flat, laterally spreading 30-mm adenoma involving the ampulla of Vater. Fig.2 Endoscopic image during underwater piecemeal ampullectomy. Fig.3 A 10-mm perforation developed after resection of the third tissue specimen.