LAUSR

Duodenal trauma usually consists of retroperitoneal lesions, which represent a small percentage of abdominal injuries. These injuries are difficult to manage by surgery, so endoscopy can be an useful alternative [1–3]. A 17-year-old man presented to the Emergency Department of a first-level care hospital after a collision with a teammate during a football match. As a result of a gradual onset of sepsis during in-hospital observation, he underwent an abdominal computed tomography (CT) scan that showed post-traumatic duodenal perforation. He therefore underwent emergency laparotomy, with two duodenal lesions found and treated by direct drainage (using transduodenal transabdominal catheters), and additional surgical drains were placed (▶Fig. 1 a). Given our expertise in the management of enteral perforations [4] and to avoid re-do surgery, an endoscopic approach was then proposed and the patient was referred to our third-level care hospital. An additional abdominal CT scan confirmed the correct position of the two catheters, alongwith a large residual fluid collection (▶Fig. 1b). Firstly, frontal view endoscopy, using 3.8-mm operative gastroscope, confirmed the two duodenal perforations, with the catheters passing through these having been fixed by surgical stitches. The two catheters were endoscopically removed after 0.035-inch guidewires had been placed through them, with one of them replaced by a tubular drain that extended 4–5cm from the duodenal lesion. Closure was firstly attempted by overthe-scope (OTS) clipping. The first OTS clip (OTSC system, Ovesco) was released at the level of the most proximal lesion; however, it was not possible to place a second OTS clip at the level of the second perforation because the distal part of the first clip was too close to the edge of the second perforation. The endoscopic strategy was therefore changed to stenting. A 4.2-mm duodenoscope was used, but cannulation of the major ▶ Fig. 1 Computed tomography scan images showing: a the position of the two transabdominal transduodenal Foley catheters with the distal ends located one in the descending portion and one in the ascending portion of the duodenum; b a large residual fluid collection extending from the horizontal portion of the duodenum to the right abdominal quadrants. ▶ Fig. 2 Follow-up computed tomography scan 15 days after the procedure showing no retroperitoneal or intraperitoneal fluid collections, with the self-expandable metal duodenal stent remaining in position.