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INTRODUCTIONDuodenal perforations are a rare complication during interventional endoscopy. Their mortality is high, and the treatment in most cases is surgical.We report a case of duodenal perforation (type I, Stapfer) (1) during an interventional endoscopic ultrasound (EUS) procedure resolved using an over-the-scope clip called OTSC®. CASE REPORTA 74-year-old woman presented obstructive jaundice. Computed tomography revealed a pancreatic head tumor with dilatation of the common bile duct (CBD) and pulmonary metastases. Biliary drainage by ERCP was indicated.Papilla had tumoral signs of infiltration. Cannulation was not achieved after several attempts with a papillotome. We accessed the distal CBD after performing a pre-cut, but the guidewire could not pass deeply. After replacing the duodenoscope with a linear echoendoscope with the intention of performing biliary drainage guided by EUS, a 10 mm duodenal perforation (type I, Stapfer) was visualized in the posterior wall of the duodenal bulb (Fig. 1A) Vol. 104. N.°9, pp. 489-490, 2012 Fig. 1. A. Duodenal perforation during biliary drainage guided by EUS. B. Endoscopic closure using an over-the-scope clip (OTSC). PICTURES IN DIGESTIVE PATHOLOGY

BackgroundIt seems that lumen-apposing metal stents (LAMS) are displacing plastic stents in the therapy of pancreatic-fluid collection in walled-off necrosis (WON). To date, there is no quality of evidence to recommend LAMS as the standard treatment in the management of WON. The theoretical benefit of LAMS over plastic stents needs to be proven.Methods/designThis is a randomized controlled, multicenter, prospective clinical trial with two parallel groups, without masking. One-hundred and fourteen patients with WON will undergo endoscopic ultrasound (EUS)-guided transmural draining in nine tertiary hospitals in Spain and will be randomized to the LAMS or plastic-stent group. The primary endpoint is the short-term (4 weeks) clinical success determined by the reduction of the collection (to < 50% or < 5 cm in size), along with clinical improvement. Secondary endpoints: long-term (4 months) clinical success (total resolution or 5 cm), procedure duration, level of difficulty, safety, and recurrences.DiscussionThe PROMETHEUS trial has been designed to determine whether LAMS are superior to plastic stents in EUS-guided transmural drainage of WON.Trial registrationClinicalTrials.gov, ID: NCT03100578. Registered on 4 April 2017. https://clinicaltrials.gov/ct2/home