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A modified EUS-guided rendezvous technique with needle-knife sphincterotomy over a transpapillary bile duct wire
VideoGIE
Digital cholangioscopy for targeted photodynamic therapy of unresectable cholangiocarcinoma
Figure 1. Digital cholangioscopic view of the common hepatic duct with diffuse infiltration by invasive cholangiocarcinoma.
A 58-year-old woman with Bismuth-Corlette classification type IV cholangiocarcinoma presented with recurrent biliary strictures. She had multiple previous admissions for recurrent cholangitis. Despite palliative radiation and chemotherapy, she had persistent biliary strictures and was referred for photodynamic therapy (PDT). Imaging revealed a 9.9 5.5 cm mass along the right and left hepatic lobes with upstream ductal dilation. Forty-eight hours before ERCP, she was given an intravenous injection of 2 mg/kg of porfirmer sodium (Photofrin, Pinnacle Biologics, Bannockburn, Ill) as a photosensitizing agent. Digital cholangioscopy and fluoroscopy were used to target the malignant stricture with the PDT fiber for photoactivation (Fig. 1). At her 2-month follow-up visit, she had not experienced recurrent cholangitis. Multiple clinical studies have shown that the addition of PDT improves This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
both median patient survival and quality of life, compared with stenting alone, for unresectable cholangiocarcinoma. The most common adverse event with PDT is from the ERCP or biliary stenting. Another adverse event of PDT is phototoxicity; therefore, all patients are instructed to avoid exposure to bright light and to wear protective clothing. Video 1 (available online at www.giejournal.org) highlights the use of digital cholangioscopy to allow for targeted photodynamic therapy as adjuvant treatment for unresectable cholangiocarcinoma. DISCLOSURE Dr Kahaleh is a consultant for Boston Scientific, Xlumina, and Maunakea and receives research funding from Gore, MI Tech, Pinnacle, and Maunakea. All other authors disclosed no financial relationships relevant to this publication. Monica Saumoy, MD, Nikhil A. Kumta, MD, MS, Michel Kahaleh, MD, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA http://dx.doi.org/10.1016/j.gie.2016.05.020
A modified EUS-guided rendezvous technique with needle-knife sphincterotomy over a transpapillary bile duct wire An 81-year-old woman was transferred to our hospital after an unsuccessful ERCP for Escherichia coli bacteremia, abnormal liver function test results, and right upper-quadrant pain. At ERCP, attempted cannulation of
the bile duct using the traditional route was unsuccessful. Thus, EUS-guided biliary access was achieved with a 19-gauge access needle into a 13-mm bile duct in a transduodenal approach. A 450-cm 0.025-inch wire was passed
862 GASTROINTESTINAL ENDOSCOPY Volume 84, No. 5 : 2016
www.giejournal.org
VideoGIE
Figure 1. A, Echoendoscopic access to the bile duct with a bile duct wire traversing the papilla into the duodenum. B, Endoscopic view of the bile duct wire placed by EUS.
in a transpapillary fashion; this was technically difficult but successful (Fig. 1A). The EUS endoscope was then exchanged over the wire, and a duodenoscope was advanced alongside the wire (Fig. 1B). Given the difficulty of placing the wire, we chose not to manipulate it and lose access. We therefore performed a needleknife sphincterotomy, using the wire as a guide to orient the direction of the bile duct (Video 1, available online at www.giejournal.org). Needle-knife sphincterotomy was successful, and bile duct access was obtained to allow for
successful bile duct stent placement. After the procedure, the patient did well. Her pain resolved, and her liver function test results slowly returned to normal. Placement of a bile duct wire by an EUS-guided rendezvous technique can orient the bile duct for successful needle-knife sphincterotomy.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
Arvind J. Trindade, MD, Ashby Thomas, MD, Divyesh V. Sejpal, MD, Sumant Inamdar, MD, Division of Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
http://dx.doi.org/10.1016/j.gie.2016.05.030
Role of enteroscopy in the diagnosis and management of adult small-bowel intussusception A 77-year-old man presented with abdominal discomfort, nonbloody emesis, melena, and syncope. His hemoglobin count was 6.2 g/dL. A CT of his abdomen showed a proximal jejunojejunal intussusception with a 2.4 cm 2.7 cm intraluminal enhancing mass as the This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
lead point (Fig. 1). Endoscopic evaluation was initially performed by use of antegrade double-balloon endoscopy (EN-450T5, Fujinon, Inc; Wayne, NJ). At 80 cm in the proximal jejunum, a jejunojejunal intussusception was found, causing near complete obstruction. The obstructed area was traversable, and the endoscope was advanced downstream. Reduction of the intussusception was achieved by keeping only the balloon of the endoscope inflated during withdrawal. A 3-cm submucosal round mass with no active bleeding was found at the area of intussusception. A cap-fitted colonoscope (EC-3490TLi, Pentax; Montvale, NJ) was Volume 84, No. 5 : 2016 GASTROINTESTINAL ENDOSCOPY 863
Digital cholangioscopy for targeted photodynamic therapy of unresectable cholangiocarcinoma
Figure 1. Digital cholangioscopic view of the common hepatic duct with diffuse infiltration by invasive cholangiocarcinoma.
A 58-year-old woman with Bismuth-Corlette classification type IV cholangiocarcinoma presented with recurrent biliary strictures. She had multiple previous admissions for recurrent cholangitis. Despite palliative radiation and chemotherapy, she had persistent biliary strictures and was referred for photodynamic therapy (PDT). Imaging revealed a 9.9 5.5 cm mass along the right and left hepatic lobes with upstream ductal dilation. Forty-eight hours before ERCP, she was given an intravenous injection of 2 mg/kg of porfirmer sodium (Photofrin, Pinnacle Biologics, Bannockburn, Ill) as a photosensitizing agent. Digital cholangioscopy and fluoroscopy were used to target the malignant stricture with the PDT fiber for photoactivation (Fig. 1). At her 2-month follow-up visit, she had not experienced recurrent cholangitis. Multiple clinical studies have shown that the addition of PDT improves This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
both median patient survival and quality of life, compared with stenting alone, for unresectable cholangiocarcinoma. The most common adverse event with PDT is from the ERCP or biliary stenting. Another adverse event of PDT is phototoxicity; therefore, all patients are instructed to avoid exposure to bright light and to wear protective clothing. Video 1 (available online at www.giejournal.org) highlights the use of digital cholangioscopy to allow for targeted photodynamic therapy as adjuvant treatment for unresectable cholangiocarcinoma. DISCLOSURE Dr Kahaleh is a consultant for Boston Scientific, Xlumina, and Maunakea and receives research funding from Gore, MI Tech, Pinnacle, and Maunakea. All other authors disclosed no financial relationships relevant to this publication. Monica Saumoy, MD, Nikhil A. Kumta, MD, MS, Michel Kahaleh, MD, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA http://dx.doi.org/10.1016/j.gie.2016.05.020
A modified EUS-guided rendezvous technique with needle-knife sphincterotomy over a transpapillary bile duct wire An 81-year-old woman was transferred to our hospital after an unsuccessful ERCP for Escherichia coli bacteremia, abnormal liver function test results, and right upper-quadrant pain. At ERCP, attempted cannulation of
the bile duct using the traditional route was unsuccessful. Thus, EUS-guided biliary access was achieved with a 19-gauge access needle into a 13-mm bile duct in a transduodenal approach. A 450-cm 0.025-inch wire was passed
862 GASTROINTESTINAL ENDOSCOPY Volume 84, No. 5 : 2016
www.giejournal.org
VideoGIE
Figure 1. A, Echoendoscopic access to the bile duct with a bile duct wire traversing the papilla into the duodenum. B, Endoscopic view of the bile duct wire placed by EUS.
in a transpapillary fashion; this was technically difficult but successful (Fig. 1A). The EUS endoscope was then exchanged over the wire, and a duodenoscope was advanced alongside the wire (Fig. 1B). Given the difficulty of placing the wire, we chose not to manipulate it and lose access. We therefore performed a needleknife sphincterotomy, using the wire as a guide to orient the direction of the bile duct (Video 1, available online at www.giejournal.org). Needle-knife sphincterotomy was successful, and bile duct access was obtained to allow for
successful bile duct stent placement. After the procedure, the patient did well. Her pain resolved, and her liver function test results slowly returned to normal. Placement of a bile duct wire by an EUS-guided rendezvous technique can orient the bile duct for successful needle-knife sphincterotomy.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
Arvind J. Trindade, MD, Ashby Thomas, MD, Divyesh V. Sejpal, MD, Sumant Inamdar, MD, Division of Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
http://dx.doi.org/10.1016/j.gie.2016.05.030
Role of enteroscopy in the diagnosis and management of adult small-bowel intussusception A 77-year-old man presented with abdominal discomfort, nonbloody emesis, melena, and syncope. His hemoglobin count was 6.2 g/dL. A CT of his abdomen showed a proximal jejunojejunal intussusception with a 2.4 cm 2.7 cm intraluminal enhancing mass as the This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
lead point (Fig. 1). Endoscopic evaluation was initially performed by use of antegrade double-balloon endoscopy (EN-450T5, Fujinon, Inc; Wayne, NJ). At 80 cm in the proximal jejunum, a jejunojejunal intussusception was found, causing near complete obstruction. The obstructed area was traversable, and the endoscope was advanced downstream. Reduction of the intussusception was achieved by keeping only the balloon of the endoscope inflated during withdrawal. A 3-cm submucosal round mass with no active bleeding was found at the area of intussusception. A cap-fitted colonoscope (EC-3490TLi, Pentax; Montvale, NJ) was Volume 84, No. 5 : 2016 GASTROINTESTINAL ENDOSCOPY 863