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A duodenal perforation is a serious complication that can occur during endoscopic retrograde cholangiopancreatography (ERCP), particularly if it is associated with therapeutic endoscopic sphincterotomy. Therefore, it is crucial to identify and manage it early to achieve the best possible outcome. Conservative management may be attempted; however, surgical intervention is required if signs of sepsis or peritonitis are present. In this case report, we present the case of post-ERCP duodenal perforation in a 33-year-old female with sickle cell disease who presented on account of abdominal pain. The patient was diagnosed with post-ERCP duodenal perforation, type 4 according to the Stapfer classification. She was subsequently treated conservatively with intravenous antibiotics, bowel rest, and serial abdominal exams. The patient noted significant interval improvement in symptoms and was subsequently discharged home. The early detection and management of suspected complications of ERCP provide a critical prognostic value.

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PURPOSE: Many techniques were used for the treatment of hydrocephalus, and ventriculoperitoneal shunt surgery is a widely used procedure. Ventriculoperitoneal shunt surgery has been associated with several complications like obstruction of the tube, infection, cerebrospinal fluid loculation, intestinal obstruction, migration of the shunt, and perforation of the intestinal organs. Perforation of the bowel owing to protrusion of ventriculoperitoneal shunt catheter from the anus is an extremely rare complication. Mini or exploratory laparotomy and revision of peritoneal part of shunt and repair of bowel perforation, or pulling out the ventriculoperitoneal shunt catheter and using external ventricular drainage and antibiotics, or colonoscopic removal of ventriculoperitoneal shunt catheter and repair of the bowel can be performed. Retrograde contamination of cerebrospinal fluid and meningitis is a very important part of the treatment in these cases. We aimed to present two cases with bowel perforation who treated with endoscopically. METHODS: We report the cases of 2 patients with transanal protrusion of VPS catheter and the management via endoscopic therapeutic options. RESULTS: Successful treatment of the patients was achieved by endoscopic removal of the catheter and endoscopic repair of the bowel perforation. CONCLUSION: If peritonitis, bowel obstruction, or abscess does not occur, endoscopic removal of shunt and bowel repairing with endoclips may be enough.

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Endoscopic retrograde cholangiography related duodenal perforation is an infrequent complication and associated with significant morbidity. The management of such perforations, especially in the setting of malignancy, is not standardized given the paucity of literature. We encountered a patient who was diagnosed with periampullary carcinoma and had a perforation in the duodenum during endoscopy. Emergency pancreatoduodenectomy (EPD) was performed considering it to be a resectable disease with minimal contamination. He had a prolonged hospital course due to surgical site infection and hepaticojejunostomy leak, however, which was managed successfully. At one year follow up, he is healthy with no evidence of recurrence. We conclude that EPD can be attempted for selected iatrogenic duodenal perforations with co-existent resectable malignancy in a stable patient. It may help to avoid the morbidity of a second surgery in the setting of a distorted anatomy and simultaneously preventing the probable upstaging of disease due to peritoneal seedling.

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BACKGROUND: Despite their low occurrence, endoscopic perforations (EPs) are concerning. Some predictive factors have been identified, and EP management is debated, whether non-surgical (medical and/or endoscopic) or surgical. The objective was to elaborate a predictive score for surgical management of EP. METHODS: All the patients addressed for upper and lower EP, except oesophageal EP, were retrospectively included (2004-2015). Demographic data, endoscopic features (indication, location, type), clinical, biological and radiological presentations of EP were reviewed. Management of EP and outcomes were recorded. A predictive score was constructed by multiple linear regression and a cut-off value for surgical management was identified. Additional subgroup analysis was performed according to the location of EP (upper and lower). RESULTS: Among 41150 endoscopic procedures, 44 patients (22 males, median age = 65 years [22-87]) presenting with EP were included (0.09%). Lower gastrointestinal (GI) endoscopy was mostly performed (66%). EP diagnosis was immediate in 73% of the cases (n = 32). Non-surgical management was efficient in 2/3 cases treated medically alone, and 18/20 cases treated by endoscopy. Surgical management was always successful (n = 24/24). In case of peritonitis, surgery was systematically required, whereas easily required in case of delayed diagnostic of EP. The EP score was based on the presence of previous abdominal surgery, lower GI endoscopy and diagnostic endoscopy. A cut-off EP score of 22.8% for surgery was chosen; it was associated with a specificity and sensitivity of 40 and 100%, respectively. When subgroups were analysed according to EP location, the EP score was still based on the presence of previous abdominal surgery and diagnostic endoscopy. The cut-off was 6.3 and 73.3% for upper (specificity: 73%, sensitivity: 100%) and lower (89 and 45%) locations, respectively. CONCLUSION: The predictive EP score may avoid inappropriate surgical management, as well as delayed surgery after non-surgical management failure. Forthcoming study should prospectively validate this score.

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Objective To evaluate the perforation repair method of purse-string suture with single channel after gastroscopy endoscopic submucosal resection (ESD) in treating gastric submucosalal stromal tumor originating from muscularis propria lay of gastric fundus. Methods 15 patients with GIST from gastric fundus muscularis propria were treated with ESD. The diameters of tumors were from 1.5 ～ 3.5 cm. Purse-string suture with single channel gastroscopy was performed for the gastric wall perforation during ESD. Results All patients underwent repair successfully. The procedure time was 10 ～ 15 min. No severe complications occurred. Conclusion Purse-string suture with single channel gastroscopy is a feasible and effective perforation repair method during ESD of gastric fundus.

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INTRODUCTION: The incidence of duodenal perforation after ERCP ranges from 0.09% to 1.67% and mortality up to 8%. METHODS: This systematic review was registered in Prospective Register of Systematic Reviews, PROSPERO. Stapfer classification of ERCP-related duodenal perforations was used. RESULTS: The systematic search yielded 259 articles. Most frequent post-ERCP perforation was Stapfer type II (58.4%), type I second most frequent perforation (17.8%) followed by Stapfer type III in 13.2% and type IV in 10.6%. Rate of NOM was lowest in Stapfer type I perforations (13%), moderate in type III lesions (58.1%) and high in other types of perforations (84.2% in type II and 84.6% in IV). In patients underwent early surgical treatment (<24 h from ERCP) the most frequent operation was simple duodenal suture with or without omentopexy (93.7%). In patients undergoing late surgical treatment (>24 h from ERCP) interventions performed were more complex. In type I lesions post-operative mortality rate was higher in patients underwent late operation (>24 h). In type I lesions, failure of NOM occurred in 42.8% of patients. In type II failure of NOM occurred in 28.9% of patients and in type III there was failure of NOM in only 11.1%, none in type IV. Postoperative mortality after NOM failure was 75% in type I, 22.5% in type II and none died after surgical treatment for failure of NOM in type III perforations. CONCLUSIONS: This systematic review showed that in patients with Stapfer type I lesions, early surgical treatment gives better results, however the opposite seems true in Stapfer III and IV lesions.

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Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.