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Successful closure of a cryotherapy-induced bleeding jejunal perforation with the over-the-scope clip system

Published:November 17, 2016DOI:https://doi.org/10.1016/j.gie.2016.10.038
      A 63-year-old man with a history of resected esophageal adenocarcinoma was found to have residual dysplasia and was referred for cryotherapy. After the procedure, the patient experienced significant abdominal distention in the recovery room. He underwent immediate repeated endoscopy and was found to have a proximal jejunal perforation (Fig. 1A). An exposed pulsatile vessel was seen at the defect, with associated oozing from the wound site. With the aid of the twin grasper device, the defect was successfully closed with the deployment of a single 11-t over-the-scope clip (OTSC) (Fig.1B; Video 1, available online at www.giejournal.org). Periprocedural fluoroscopy did not show any extravasation of contrast material. An upper GI series on hospital day 4 showed negative results, and the patient was discharged on hospital day 5. We hypothesized that the perforation was secondary to cryotherapy-induced barotrauma to a jejunal diverticulum. The OTSC system is a safe and effective alternative to conventional metal clips for perforation closure of small defects, and it can prevent inadvertent injury to adjacent vessels and structures. In this case, the twin grasper tool was able to oppose the defect edges during direct observation of the extraluminal structures, thereby preventing nearby vessel injury. For small-bowel perforations, this may be particularly important, given that most of the small bowel is unfixed, and the tendency to capture extraluminal structures may be more with a traditional clip closure.
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      Figure 1A, Acute jejunal perforation. B, After placement of the over-the-scope-clip.
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