CASE REPORT Successful closure of a complicated duodenal ulcer perforation with an expandable esophageal stent George Stavrou, 1 Vasileios Rafailidis, 2 Anna Diamantidou, 1 Constantinos Kouskouras, 2 Antonios Michalopoulos 1 & Katerina Kotzampassi 1 1 Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece 2 Department of Radiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece Keywords: Duodenal; perforation; stent Correspondence George Stavrou, Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, St. Kyriakidi 1, 54006 Thessaloniki, Greece. Tel/Fax: +30 2310 993496 Email: stavgd@gmail.com Received 21 December 2017; revised 17 June 2018; accepted 22 July 2018 DOI: 10.1111/ases.12642 Abstract Laparotomy and reoperation remain the standard procedures for patients with suture line disruption after the initial surgical treatment for duodenal ulcer perforation has failed. Recently, endoscopic stents have been employed for dehiscence of the suture line after a surgical repair or even as a primary treatment. We present such a case, the fourth in the literature. In this case, a partially covered stent was placed to cover the duodenal perforation opening after an unsuccessful stitching 6 days earlier. We discuss the difficulties in stent positioning, the choice of sealant, and possible complications. Overall, for older patients with comorbidities, endoscopic stent placement could be considered a promising alternative minimally invasive treatment. Introduction Although increasingly rare, duodenal ulcer perforation continues to be a significant clinical problem, with a high mortality rate, especially in the elderly (1). Although surgery remains the gold standard, there have been cases of suture line disruption or persistent leakage; these have mainly occurred in patients with large or chronic ulcers or in patients with peritoneal inflamma- tion/sepsis or immunosuppression. Endoscopic stent placement poses an attractive, minimally invasive alter- native that can be used either as a primary treatment or to manage suture line dehiscence in patients unfit for surgery (2). Case Presentation An 84-year-old woman with hypertension and cardiac insufficiency was referred to our department 6 days after a dehiscence of the suture line of a perforated duodenal ulcer. She had previously undergone laparotomy and simple suture with interrupted 3-0 polyglactin 910 sutures and an omental patch (Graham patch) 30 h after the onset of symptoms. On postoperative day 3, there was duodenal content leakage (500–700 mL/day) through the abdominal drainage system. Parenteral nutrition and antibiotics were given, and oral intake was withheld. Although there were no signs of peritoneal irritation or evidence of intra-abdominal collection on the CT scan, her white blood cell count (15 000/μL, 80% neutrophils), in association with her age and comorbidities, persuaded her medical team to transfer her to us. Upon admission, diagnostic endoscopy revealed a huge duodenal bulb opening on the anterior wall (Figure 1). Because of the patient’s age and comorbid- ities, the time from perforation to suture, and the large gap, reoperation or endoscopic application of clips, over- the-scope clips, or fibrin glue was rejected; therefore, a partially covered, distally released 9-cm esophageal stent (Ultraflex, US/18-10/16/95; Boston Scientific, Marlbor- ough, MA, USA) was placed over a 360-mm, 0.09mm guidewire (Savary-Gilliard SGW-360-SD; Cook Medical, Castletroy, Limerick, Ireland) to cover the defect (Figure 2). The procedure lasted approximately 30 min and was performed in our endoscopy suite; there was no sedation besides lidocaine pharyngeal spray. Over the next 3 days, the leakage decreased rapidly to 10–30 mL/ day and then stopped. On postoperative day 8, the abdominal drain was removed after the gap had been checked for complete closure with a CT scan with intra- venous and oral contrast (Figures 3,4). Two days later, Asian J Endosc Surg (2018) © 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd 1 Asian J Endosc Surg ISSN 1758-5902