A52 ENDOSCOPIC CLOSURE OF PERFORATED PEPTIC ULCER IN A PATIENT WHO WAS A CHALLENGING CANDIDATE FOR SURGICAL MANAGEMENT

The incidence of peptic ulcer disease (PUD) in developed countries has overall decreased but is still seen commonly in patients above the age of 60. The commonest complication of PUD is hemorrhage (73%) followed by perforation (9%) and obstruction (3%). Perforated peptic ulcer (PPU) is associated with a mortality of at least 25%. Traditionally, PPU is managed surgically, however the postoperative course is also associated with a high risk of complications and mortaliy. To describe the first case report of endoscopic loop and clips closure technique used for perforated gastric ulcer, augmented by video. We describe a case of a 68 year old patient with complicated past medical and surgical history who presented 9 days post small bowel resection for a partial small bowel obstruction with an acute abdomen. CT scan demonstrated a large collection in the left upper quadrant and free air, confirming perforation. He was brought to the Operating theatre emergently for an exploratory laparotomy due to his unstable status. As he had a “frozen abdomen” from severe adhesions from previous surgeries, the surgery team was unable to repair the perforation. The left upper quadrant was irrigated and a sump drain inserted. Repeat CT scan post op showed features consistent with persistent perforation. The Gastroenterology team was consulted for endoscopic closure of the perforations. Two perforated gastric ulcers were successfully repaired with the loop and clips technique. Repeat endoscopy after showed complete healing of the defects. This case presentation is augmented by video. This is the first report of the endoscopic loop and clips closure technique used for a perforated gastric ulcer, with successful outcomes. PPU is associated with a high rate of mortality and morbidity and traditionally is managed emergently by surgery. Post operative mortality for PPU is estimated to be 6–10%, and is 3 to 5 times higher in the elderly population. Endo et al first described the loop and clips technique in 2004. In the literature, multiple other techniques are described for endoscopic closure of defects PUD is commonly seen in the elderly population, PPU is a rare but dangerous complication. In our patient, who was a challenging candidate for surgical management, endoscopic repair of PPU with the loop and clips technique was successful. In select patients perhaps endoscopic repair of PPU with the loop and clips technique may be a simple and feasible alternative to operative management and its associated high risk of complications, costs of prolonged hospital stay and mortality. None

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