Endoscopic treatment of duodenal fistula after incomplete closure of ERCP-related duodenal perforation

Figure 1 Initial abdominal computed tomography and endoscopic findings during endoscopic retrograde cholangiopancreatography. A: Computed tomography showed a small common bile duct stone (thin white arrow); B: During endoscopic retrograde cholangiopancreatography, a 10 mm-sized perforation developed in the lateral wall of the duodenal bulb during inadvertent rapid withdrawal of the duodenoscope (thick black arrow); C and D: Multiple hemoclips and an endoloop were immediately applied for the defect closure.

Figure 2 Chest X-ray after endoscopic retrograde cholangiopancreatography. The scan shows a large amount of pneumoperitoneum below both the hemidiaphragms.

Figure 3 Follow-up abdominal computed tomography after duodenal perforation. No contrast leakage was detected into the peritoneum at the periduodenal lesion after endoscopic treatment; however, a moderate amount of pneumoperitoneum was present.

Figure 4 Second follow-up abdominal computed tomography after duodenal perforation. The scan shows a small fistula communicating with the peritoneal space, at the previous perforation site in the duodenal bulb (arrow), and absence of a common bile duct stone.

Figure 5 Endoscopic findings of the second endoscopic closure. A: A suspicious fistulous opening was detected at the previous perforation site (arrow); B: An application of additional multiple hemoclips and fibrin glue injection was successfully performed at the site of the suspicious fistulous opening.