S5335 Endoscopic Closure of Gastric Perforation in a Patient With Liver Failure

Introduction: Gastric perforation involves full thickness injury to the wall. It carries a very high-risk mortality in patients with decompensated liver disease and acute liver failure. Patients have been historically managed with surgical intervention to prevent further leakage of gastrointestinal contents, risk of peritonitis and abscess formation. Alternative approach includes endoscopic repair. Case Description: Sixty-six-year-old male patient with past medical history of morbid obesity who presented with worsening abdominal pain of 3 days duration. Abdominal imaging was significant for cirrhotic liver and gastric perforation. The patient underwent emergent laparotomy and gastric perforation was managed with Graham patch repair. The patient was started on a clear liquid diet. However, on postoperative day 9, his pain reoccurred, and he developed purulent output from Jackson-Pratt drain. Upper gastrointestinal (GI) series was performed which confirmed persistent perforation. Patient was deemed to be a very high-risk surgical candidate for mortality due to worsening comorbidities including cirrhosis secondary to metabolic dysfunction-associated steatohepatitis, and development of hepatorenal syndrome requiring dialysis. Model for End-Stage Liver Disease-sodium score had worsened to 43 points (90-day mortality risk of 95.9%). Mayo clinic post-operative mortality risk in patients with cirrhosis was also calculated to be 94.3% at 7 days interval. Goals of care were discussed and the decision was made to attempt endoscopic repair because the patient had high surgical risk for mortality. Endoscopic repair was performed by application of Argon Plasma Coagulation (APC) ablation followed by clip closure (Mantis Clip × 2- Boston Scientific, Lockado 16 mm clip × 4-Microtech). Successful repair was confirmed fluoroscopically. A repeat upper GI series was performed which confirmed successful repair of gastric antral leak and diet was resumed. Discussion: This case highlighted the importance of providing appropriate, minimally invasive, and timely interventions. Peptic ulcers carry a significant risk of mortality when not managed effectively. This presented a unique opportunity to explore an alternative approach as the patient was a very high-risk surgical candidate. Endoscopic intervention spared him the additional risks associated with another surgery, improving patient outcomes. Compiling additional data on this technique may help determine whether it offers significant advantages over traditional surgical re-exploration, potentially shaping future clinical guidelines.