Endoscopic Repair of Delayed Stomach Perforation Arising From Penetrating Trauma: A Case Report

Primary endoscopic closure of perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are only few studies on the ecacy of endoscopic management in traumatic delayed gastric perforation. Here, we report the case of a 39-year-old woman who presented with multiple penetrating trauma in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and perisplenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suture of the lacerated lung was performed; however, delayed free-perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for primary repair of the gastric wall, re-perforation was noted 15 d post-operatively. The high re-operation risk prompted an endoscopic intervention using two endoloops and 11 endoscopic clips using a novel modied purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications.

with omental reduction and suture of the lacerated lung was performed; however, delayed free-perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for primary repair of the gastric wall, re-perforation was noted 15 d post-operatively. The high reoperation risk prompted an endoscopic intervention using two endoloops and 11 endoscopic clips using a novel modi ed purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications.

Conclusions
Endoscopic closure with this novel technique involving endoloops and endoscopic clips can be a useful therapeutic alternative to re-operation for delayed gastric perforation caused by penetrating trauma.

Background
Stomach perforation due to trauma is an emergent critical condition, and immediate management of the perforated gastric wall is highly essential. Gastric trauma has a very high mortality rate (19-43%), and a majority of the cases require primary surgical repair [1] .
Although surgical management of gastric perforation is generally effective in traumatic stomach perforation, in situations wherein surgery is unfeasible or in a stable patients without sepsis, endoscopic treatment modalities can be considered as alternatives. Endoscopic treatment method with an endoloop and clips (purse-string suture technique) has showed good results in few reports for large iatrogenic gastrointestinal (GI) perforation closures caused after endoscopic therapeutic procedures [2][3][4] . Also a case report exhibited successful closure of small gastric penetrating stab wound with clips. [5] Endoscopic treatment might be an effective option to treat GI perforation owing to it being minimally invasive, and associated with fast recovery and relatively low costs compared to surgery. [6] However, there is limited data on the e cacy of endoscopic closures for trauma-induced delayed GI tract perforation and anastomotic leakage. This is the rst case report on the successful execution of a novel modi ed endoscopic purse-string suture technique for delayed stomach perforation after primary surgical repair.

Case Presentation
A 39-year-old woman was rushed to the emergency department due to multiple penetrating stab wounds from a knife. Initial vital signs were stable (blood pressure: 120/60 mmHg, heart rate: 84/min, respiratory rate: 16/min, and body temperature: 36. which were later forcibly removed by the patient due to post-operative delirium. On POD 9, follow-up CT revealed peritonitis with a multi-loculated abscess in the upper abdominal cavity, which was drained using a percutaneous drainage (PCD) catheter. To screen for possible undetected small perforations, upper gastrointestinal (UGI) series performed on POD 12 with gastrogra n showed no signs of leakage at the perforation site. The daily amount of PCD decreased; however, CT on POD 18 detected a disrupted gastric wall with remaining uid collection. UGI series also revealed prominent leakage (Figure 3a and   3b). Due to the short 14-d interval from the most recent surgery, severe adhesion and in ammation in the operative eld were presumed. Therefore, there was a high-risk associated with a reoperation. Hence, we decided to conducta primary closure using a double-channel endoscope (Olympus GF UCT 260, Tokyo, Japan) under sedation with intravenous propofol.
Esophagogastroduodenoscopy (EGD) revealed a 2-cm free perforation in the gastric wall of the upperbody/greater-curvature with a large amount of pus draining into the stomach cavity via the perforated lumen (Figure 4a). Steps for the purse-string technique are as follows: First, an endoloop is placed at the perforation site. The rst clip is then placed at the proximal defect site and the endoloop is anchored on the perforated lesion mucosa. The subsequent clips x the endoloop beside the previous clips. After the endoloop and clips encircle the defect, the rim of the opening is approximated by fastening the endoloop using the purse-string technique. [7] However due to severe edema and friability of the gastric mucosa, we attached four xing clips (Optimos TM disposable clip, Taewoong Medical, Gimpo, South Korea) as pillars at the margin of the perforated lumen in advance. Then, we placed an endoloop (Olympus HX-20U-1, Tokyo, Japan) encircling the margin of the attached clips, and xed it to the gastric mucosa using seven additional endoscopic clips (Figure 4b). Finally, we fastened the endoloop, which tightened and secured the perforated lumen (Figure 4b). Follow-up CT and EGD at POD 25 revealed a successfully healed gastric lumen and a decreased loculated uid collection (Figure4c). Feeding was initiated on POD 39 and she was discharged on POD 46 without other complications.

Discussion And Conclusions
Gastric perforation may be caused by trauma, malignant tumors, benign ulcers, and iatrogenic factors such as endoscopic procedures. Severe gastric injuries secondary to penetrating abdominal trauma occur in 7-20% of the cases, and are associated with several complications [8] . Injuries to other visceral organs can occur in 65-74% of the cases [9] , and liver lacerations can co-exist with these injuries, especially diaphragmatic injury [10] . Physicians should be aware of delayed gastric perforation, because a super cial injury of the gastric wall can progress to free perforation [11] . In our case, the initial CT scan showed only splenic hemorrhage with diaphragmatic injury, but the patient developed free gastric perforation after 3 d; we believe that a thorough surgical exploration of the abdominal cavity during the rst operation could have prevented delayed gastric perforation [9,12] . Furthermore, we believe that the second delayed perforation of the stomach wall occurred due to perigastric uid accumulation that may have interrupted stomach wall healing.
The treatment modality differs depending on the etiology and severity of the gastric perforation. Therapeutic endoscopy can promptly identify free perforation of the gastric wall, thereby allowing adequate and successful management. Accordingly, recent studies have demonstrated good results from on-site endoscopic closure of GI tract perforations [3,13] . However, the immediate detection and management of free perforation may be di cult in gastric perforation from an external force, such as blunt or penetrating trauma. With delayed perforation, endoscopic closure of the perforation site may be challenging due to bowel edema, in ammation, and brosis of the surrounding tissues.
Our case suggests that when surgery is unfeasible due to unexpected patient conditions, such as delayed gastric re-perforation or leakage from the repair site, salvage treatment using endoscopy may be preferable to re-operation, which is associated with high morbidity and mortality [14] . Endoloops and endoscopic clips for the closure of GI tract perforation are effective treatment modalities [2,3] . However, existing studies have only reported on the e cacy of on-site endoscopic closure for early GI perforation and have limited data for delayed GI tract perforation and anastomotic leakage after trauma. Our case offers a novel technique for these situations. Thus, for swollen and friable gastric mucosa (often observed in traumatic gastric perforation), using the modi ed purse-string technique (i.e., placing the "pillar clips" before the endoloop to retain a su cient margin of the perforated lumen) over the conventional purse-string technique may be more appropriate. Regrettably, an extensive abdominal examination during the rst surgery may have identi ed the gastric injury and prevented perforation and complications. Therefore, thorough surgical exploration of the abdominal cavity should be considered in cases of abdominal trauma, especially those with penetrating diaphragmatic injury.
In conclusion, endoscopic treatment using this novel modi ed purse-string technique can successfully manage delayed re-perforation of the stomach due to trauma, without complications or subsequent surgery. The successful implementation of the modi ed purse-string technique in this case merits further study for both safety and e cacy in large scale trials. Ethics approval and consent to participate:

Abbreviations
The patient provided written informed consent for the publication of this case report (in accordance with the Declaration of Helsinki).

Consent for publication:
Obtained Availability of data and materials: Figure 1 Initial computed tomography scan of the abdominal cavity. This scan shows left hemidiaphragmatic injury with herniation (1a, yellow circle), left hemopneumothorax (1b, blue line), and perisplenic hemorrhage without signs of gastric perforation (1c, green circle).   Primary closure of perforated gastric wall with endoscopic procedure. Endoscopic ndings of the reperforated gastric lumen (a) and primary closure of the gastric lumen with endoloops and clips using the modi ed purse-string technique (b). Final endoscopic and computed tomography ndings on postoperative day 25 showing a well-healed gastric wall (c).