A 74-year-old woman was admitted for obstructive jaundice.
Computed tomography showed a pancreatic head tumor with extrahepatic bile duct dilatation and lung metastases.
Biliary drainage was indicated by ERCP.
The papilla showed signs of tumoral inversion.
Biliary cannulation was not achieved after several attempts papillotomosis and placement of distal anastomosis was achieved without advancing the guidewire through the stenosis.
The duodenum was changed to a linearly determined duodenum with the intention of performing a biliary drainage guided by endoscopic ultrasound, and a 10 mm perforation (type I, Stapfer) was visualized in the posterior duodenal wall.
A non-traumatic OTSC (9.5 to 11 mm) clip was placed with fixation clip and two endoclips were applied on a margin to ensure complete sealing.
Abdominal CT reported retropneumoperitoneum without free fluid.
The patient was kept on an absolute diet and antibiotic therapy.
The gastrointestinal transit at 5 days showed no leaks.
Oral diet was restarted on the sixth day and biliary drainage was completed by HSCT.
