Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Figure 1 Endoscopic images of four cases demonstrating a large perforation on bulb and lateral wall of the second portion of duodenum, and successful primary endoscopic closure using multiple endoclips.

Figure 2 A simple abdomen X-ray shows both subphrenic pneumoperitoneum (A) and 6 d later, the follow-up upper gastrointestinal investigation (UGI) reveals no contrast leaks (B).

Figure 3 An abdominal computed tomography (CT) shows a severe pneumoretroperitoneum (A), and follow-up UGIs done 6 d later reveal no contrast leaks (B).

Figure 4 Initial abdominal CT following perforation shows pneumoperitoneum and subcutaneous emphysema (A), and follow up UGIs performed 8 d later reveal no contrast leaks (B).

Figure 5 Abdominal CT images showing a pneumoretroperitoneum, and subcutaneous emphysema following perforation (A) and a marked improvement 4 d after conservative management (B).