Iatrogenic Stapfer type-1 duodenal perforations during endoscopic retrograde cholangiopancreatography (ERCP) typically necessitate surgical management and carry significant morbidity and mortality risk. Here, we present a case of a large duodenal perforation during ERCP managed endoscopically with an over-the-scope clip (OTSC) and describe the subsequent post-procedural management. An 80-year-old woman presented to the emergency department with acute cholangitis. Abdominal ultrasound scan revealed a dilated biliary tree with echogenic material in the common hepatic and intrahepatic ducts. The patient proceeded to ERCP, where filling defects consistent with stones were found in the proximal main bile duct on cholangiogram. Stone retrieval was complicated by a large iatrogenic perforation of the infero-lateral duodenal wall, distal to the major ampulla (Stapfer type-1). Following unsuccessful attempts to close the defect using through-the-scope clips, a decision was made to attempt closure endoscopically using an OTSC. The duodenoscope was exchanged for a forward-viewing gastroscope mounted with the OTSC. The perforation defect was fully suctioned into the cap and the clip was successfully deployed. Subsequent on-table fluoroscopy with contrast injection did not demonstrate any extra-luminal contrast leak. The patient developed a post-procedure infra-duodenal collection, however, made a complete recovery with bowel rest, negative pressure regulation at the site of the OTSC using a dual-lumen nasogastric/nasojejunal feeding tube and intravenous piperacillin-tazobactam. Thus, OTSCs potentially offer a safe and effective endoscopic treatment modality for the immediate management of ERCP-related Stapfer type-1 duodenal perforations.

Optimal needle size in achieving greatest diagnostic yield from EUS- guided FNA remains unclear. Aim: We prospectively compared sample adequacy and safety of FNA of solid lesions between 25G and 22G needle at two tertiary centres. Method: Prospective data from two sites was collected between November 2008 and November 2011. A single operator alternated on a case-by-case basis between a 25G and 22G needle. A cytopathologist was present to assess adequacy of sample. The operator could switch needle size if required.

Capsule endoscopy (CE) is a widely used method for evaluation of the small bowel. However it does have limitations; visualisation of the small bowel mucosa is often impaired due to the presence of food residue, air bubbles and bile pigments ( 1 Park S.C. et al. Effect of Bowel Preparation with Polyethylene Glycol on Quality of Capsule Endoscopy. Dig Dis Sci. 2011; 56: 1769-17752 Crossref PubMed Scopus (46) Google Scholar ). The effect of bowel preparation on improving visualisation of the small bowel varies ( 2 Viazis N. et al. Bowel preparation increases the diagnostic yield of capsule endoscopy: A prospective, randomised controlled study. Gastrointest Endosc. 2004; 60: 534-5383 Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar , 3 Dai N. et al. Improved Capsule Endoscopy after Bowel Preparation. Gastrointest Endosc. 2005; 61: 28-314 Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar 4 Fireman Z. et al. Capsule Endoscopy: Improving transit time and image view. World J Gastroenterol. 2005; 11: 5863-58665 Crossref PubMed Scopus (78) Google Scholar ) and is inconvenient for patients. ( 5 Beltran V.P. et al. Evaluation of Different Bowel Preparations for Small Bowel Capsule Endoscopy: A Prospective, Randomised, Controlled Study. Dig Dis Sci. 2011; 56: 2900-29056 Crossref PubMed Scopus (48) Google Scholar ) We aimed to prospectively evaluate the effects of 2 different bowel preparations on visualisation of the small bowel and on overall diagnostic yield compared with standard dietary changes.