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A rare case of widely metastatic cholangiocarcinoma presenting as ovarian carcinoma
ERCP-BILIARY I"417
419
BIIJARY STRICrURE MEASUREMENT AND S'I'ENT SELECTION D o n a l d G. Seibert M-D. a n d l a h n H a n s e n M.D. Robert C Byrd HSC, Morgantown ~ : Biliary d r a i n a g e with plastic stents is optimized by p l a c e m e n t o1 the shortest stent which still traverses the site of obstruction. Stent selection is entirely d e p e n d e n t u p o n stricture m e a s u r e m e n t . Methods: The stricture to d u o d e n a l d i s t a n c e w a s m e a s u r e d with a ruled c a t h e t e r (Contour C a t h , Boston Scientific), by m e a s u r e d withdrawal o1 a held guide wire, a n d by films obtained during 52 EHCPs in I:xatients with bile obstruction. The r a w Xray value w a s converted to true distance using the e n d e s c o p e magnification ratio for e a c h study. A 10F Cotton-Leung stent (Wilson Cook Meal) w a s c h o s e n b a s e d u p o n the ruled c a t h e t e r m e a s u r e a n d then p l a c e d with the distal flap in contact with the ampulla. The d i s t a n c e the guide wire w a s withdrawn from the tip of the placed stent to top of stricture minus the calculated tip location for e a c h m e t h o d ef stricture m e a s u r e m e n t d e t e r m i n e d selection a c c u r a c y . [Calculated tip location = Labeled stent length -.9 (the distance b e t w e e n flaps) + 1.8 (distance from proximal flap to tip) - stricture measurement]. Results: Mean stricture lengths a s d e t e r m i n e d by c a t h e t e r w e r e 6.6 + 2 c m s , by wire were 6.9 + 2 c m s a n d by Xray w e r e 6.7 + 2.1 cms. Correlation coefficients of the ruled c a t h e t e r m e a s u r e s with respect ,to wire withdrawal a n d Xrc~ m e a s u r e m e n t were .97 a n d .79 .
A RARE CASE OF WIDELY METASTATIC CHOLANGIOCARCINOMA PRESENTING AS OVARIAN CARCINOMA P.Sharma, P.Jaffe, A.Bhattacharyya. University Medical Center, University of Arizona, Tucson AZ g5724.
A c c u r a c y (Stent length a b o v e stricture minus c a l c u l a t e d length) Catheter M e a s u r e I
Wire M e a s u r e 2
[ Xray M e a s u r e s
.59+.2cm I .s6__+ .s e m I 1 . 2 3 + L1 c m [1 vs 3 a n d 2 vs 3 p<.001] An inappropriate stent w a s never picked by c a t h e t e r . If picked by wire, 1 stent would have b e e n long a n d 1 too short (p<.009). Using XrcW, 8 stents would b e long a n d 6 short(p<.001). These 6 slents'were all in the 29 patients with strictures beginning > 6 c m proximal to the ampullary orifice. Conclusions: 1) Ruled catheter a n d wire withdrawal best predicted stent placement. 2)Measuring stricture location from Xray film would have resulted in a less t h a n optimal stent selection in 27% of these c a s e s .
Metastatic cholangioearcinoma is a very rare disease. Less than 10% of patients are found to have peritoneal earcinomatosis. We describe an unusual case of obstructive jaundice secondary to cholangiocarcinoma and widespread metastasis who presented initially with ovarian cancer. A 59 year old white female was referred to the gastroenterology service for evaluation of jaundice. She had presented to her physician one month back with complaints of abdominal distention. Work up had revealed bilateral ovarian masses with peritoneal s p r e a d . . She underwent an exploratory laparotomy 3 weeks prior which revealed ovarian, peritoneal, omental, liver, gallbladder and small bowel tumor studding. Histopatbology was consistent with metastatic ovarian cancer. On presentation with jaundice, a CT scan of the abdomen revealed a dilated common bile duct(CBD) and findings consistent with peritoneal carcinomatosis without evidence of gallstones or choledocholithiasis. Her laboratory work up was significant for a serum bilirubin level of 7.3 mg/dl and an alkaline phosphatase seven times upper limits of normal. An ERCP was performed which revealed an irregular 3.5 cm. distal CBD stricture without stones. Brush cytology was obtained and a 68 mm wallstent (Schneider, Minneapolis MN.) was successfully placed across the stricture. The patiera clinically improved with resolution of jaundice. Cytology was positive for primary adcnoearcinoma of the CBD (cholangioearcinoma). Review of histopathology specimens from ovarian, peritoneal, omental, liver, gallbladder and small bowel tumor studding was consistent with metastatic cholangiocarcinoma. The initial pathology was misleading since the patient did have a low grade, localized mutinous cystadenocarcinomaof the right ovary. Conclusion: While metastatic cbolangiocarcinoma is an extremely rare condition, it needs to be considered when widespread earcinomatosis accompanies biliary obstruction. Unfortunately, the prognosis of such patients is dismal and palliation'remains the mainstay of therapy. Medline review failed to reveal any reported cases of ovarian metastasis from cholangiocarcinoma, so this likely represents the first such report.
418
t420
THE RISK OF POST E R C P PANCREATITIS W I T H AND WITHOUT SPHINCTEROTOMY IN PATIENTS UNDERGOING BILIARY STENT PLACEMENT. MA Shaft, RM Bashir, FH AI-Kawas, DF Fleischer, SB Benjamin. Deparlment of Medicine, Georgetown University Medical
ARE THE PATENCY RATES FOR 10 FRENCH AND 11.5 FRENCH STENTS DIFFERENT FOR COMMON DUCT OBSTRUCTION AND HILAR OBSTRUCTION? RANDOMIZED, PROSPECTIVE STUDY. h.~..S.ke,~m, G. Lehman, D. Earle, E. I aTsridis, J. Frakes, J. Johanson, T. Qaseem, D. Howell, Indiana University Medical Center, Indianapolis, IN; Rockford GE Associates, Rockford, IL; Maine Medical Center, Portland, ME When used for malignant obstruction of the common duct, expandable metal stents have been shown to have longer patency rates than standard 10 French biliary eadoprostheses (Lancet, 1992;340:1488). The differences in stent patency rates for hilar obstruction are less clear (GI Enclose 1993;39:310A). We postulated that similar findings would be seen when comparing 10 French and 11.5 French stents. METHODS: The study population consists of 212 patients with malignant bile duct obstruction; 46 had hilar and 166 common duct obstruction. Tumor types for the hilar group included bile duct (46%), metastatic (28%), gallbladder (13%), and other (13%). Tumor types for the common duct group included pancreatic (70%), bile duct (15%), metastatic (11%), gallbladder (1%), and other (3%). Following guidewire advancement proximal to the stricture, the patient was randomized to a 10 French or an 11.5 French biliary stent. Patients with hilar and common duct obstruction were randomized separately. Patients were prospectively followed up every l to 2 months to assess for symptoms of stem ocdnsion and to determine the clinical response rate. Stent related interventions and hospital days resulting from stem dysfunction were tallied. The change in total bilirubin between baseline and 30 day post-stenting was compared. The groups were similar with regards to age, minor type, tumor location, and baseline bilirubin. RESULTS: Hilar Common Duct IOF II.SF P 10F II.5F P
Center,Washington D . C .
Background:Endoscopic Sphincterotomy (ES) prior to the placement of biliary stent is frequently performed,hnwever, data evaluating the utility and complications of this approach are limited.Our aim was to compare post ERCP complications in patients who underwent biliary stent insertion with and without ES. Methods:All patients undergoing stem placement from 1989 to 1995 were evaluated.Data collected included patient demographics,procedural indieation,stent size,antecedent endoscopic therapy and ES and stent related complications. Patients with prior biliary sphinterotomy and with pancreatic stents were excluded. Results:Among the 148 patients (76 M, 72 F) who underwent stent placement over a 6 year period 61 patients underwent ES at the time of stent placement, 87 patiems had stent placed without sphincterotomy. The groups were matched for age, sex, procedural indication and stem size. Eight patients (5,4%) had complications requiring hospitalization. There was no procedure related perforation or death. Stem w/F.S. Stem only P value Total patients Complications
n=61
n=87
Bleeding 3(4.9%)" -ns Pancreatitis --2(2.3%) ns Abdominal pain 1(1.6%) 2(2.3%) ns Total 4 4 ns Condusions: There was no statistically significant difference in the rate of complications in patients undergoing biliary stem placement with or without sphinctemtomy . ES at the time of stem placemem does not decrease the risk ofpost ERCP pancreatitis and is not necessary for routine biliary stem placemem.
VOLUME 43, NO. 4, 1996
t.=77)
(,~=st)
BillmbinDecrease(mg/dl) 7.5 10.I .05 9.6 lO.O .87 Stent Sun,lent Days 183 311 .24 115 152 .99 patleat SurvivalDays 142 170 .37 286 184 .86 Stent RelatedHeap.Days 1.6 1:2 .45 1.6 2.9 .30 Stent Relatedlnterventiom .58 .43 .43 .92 .85 .88 S U M M A R Y : 1) A trend for improved patency rates was seen for the 11.5 French stent for conunon duct obstruction. This did not translate into a reduction in the number of stent related interventions and hospital days for stem dysfunction. 2) There was no statistical improvement in the stent patancy rates for 11.5 French stents for hilar obstruction. CONCLUSION: These results suggest that larger stents may be more effective for providing longer periods of drainage in common duct obstruction. This study is ongoing.
GASTROINTESTINAL ENDOSCOPY
395
419
BIIJARY STRICrURE MEASUREMENT AND S'I'ENT SELECTION D o n a l d G. Seibert M-D. a n d l a h n H a n s e n M.D. Robert C Byrd HSC, Morgantown ~ : Biliary d r a i n a g e with plastic stents is optimized by p l a c e m e n t o1 the shortest stent which still traverses the site of obstruction. Stent selection is entirely d e p e n d e n t u p o n stricture m e a s u r e m e n t . Methods: The stricture to d u o d e n a l d i s t a n c e w a s m e a s u r e d with a ruled c a t h e t e r (Contour C a t h , Boston Scientific), by m e a s u r e d withdrawal o1 a held guide wire, a n d by films obtained during 52 EHCPs in I:xatients with bile obstruction. The r a w Xray value w a s converted to true distance using the e n d e s c o p e magnification ratio for e a c h study. A 10F Cotton-Leung stent (Wilson Cook Meal) w a s c h o s e n b a s e d u p o n the ruled c a t h e t e r m e a s u r e a n d then p l a c e d with the distal flap in contact with the ampulla. The d i s t a n c e the guide wire w a s withdrawn from the tip of the placed stent to top of stricture minus the calculated tip location for e a c h m e t h o d ef stricture m e a s u r e m e n t d e t e r m i n e d selection a c c u r a c y . [Calculated tip location = Labeled stent length -.9 (the distance b e t w e e n flaps) + 1.8 (distance from proximal flap to tip) - stricture measurement]. Results: Mean stricture lengths a s d e t e r m i n e d by c a t h e t e r w e r e 6.6 + 2 c m s , by wire were 6.9 + 2 c m s a n d by Xray w e r e 6.7 + 2.1 cms. Correlation coefficients of the ruled c a t h e t e r m e a s u r e s with respect ,to wire withdrawal a n d Xrc~ m e a s u r e m e n t were .97 a n d .79 .
A RARE CASE OF WIDELY METASTATIC CHOLANGIOCARCINOMA PRESENTING AS OVARIAN CARCINOMA P.Sharma, P.Jaffe, A.Bhattacharyya. University Medical Center, University of Arizona, Tucson AZ g5724.
A c c u r a c y (Stent length a b o v e stricture minus c a l c u l a t e d length) Catheter M e a s u r e I
Wire M e a s u r e 2
[ Xray M e a s u r e s
.59+.2cm I .s6__+ .s e m I 1 . 2 3 + L1 c m [1 vs 3 a n d 2 vs 3 p<.001] An inappropriate stent w a s never picked by c a t h e t e r . If picked by wire, 1 stent would have b e e n long a n d 1 too short (p<.009). Using XrcW, 8 stents would b e long a n d 6 short(p<.001). These 6 slents'were all in the 29 patients with strictures beginning > 6 c m proximal to the ampullary orifice. Conclusions: 1) Ruled catheter a n d wire withdrawal best predicted stent placement. 2)Measuring stricture location from Xray film would have resulted in a less t h a n optimal stent selection in 27% of these c a s e s .
Metastatic cholangioearcinoma is a very rare disease. Less than 10% of patients are found to have peritoneal earcinomatosis. We describe an unusual case of obstructive jaundice secondary to cholangiocarcinoma and widespread metastasis who presented initially with ovarian cancer. A 59 year old white female was referred to the gastroenterology service for evaluation of jaundice. She had presented to her physician one month back with complaints of abdominal distention. Work up had revealed bilateral ovarian masses with peritoneal s p r e a d . . She underwent an exploratory laparotomy 3 weeks prior which revealed ovarian, peritoneal, omental, liver, gallbladder and small bowel tumor studding. Histopatbology was consistent with metastatic ovarian cancer. On presentation with jaundice, a CT scan of the abdomen revealed a dilated common bile duct(CBD) and findings consistent with peritoneal carcinomatosis without evidence of gallstones or choledocholithiasis. Her laboratory work up was significant for a serum bilirubin level of 7.3 mg/dl and an alkaline phosphatase seven times upper limits of normal. An ERCP was performed which revealed an irregular 3.5 cm. distal CBD stricture without stones. Brush cytology was obtained and a 68 mm wallstent (Schneider, Minneapolis MN.) was successfully placed across the stricture. The patiera clinically improved with resolution of jaundice. Cytology was positive for primary adcnoearcinoma of the CBD (cholangioearcinoma). Review of histopathology specimens from ovarian, peritoneal, omental, liver, gallbladder and small bowel tumor studding was consistent with metastatic cholangiocarcinoma. The initial pathology was misleading since the patient did have a low grade, localized mutinous cystadenocarcinomaof the right ovary. Conclusion: While metastatic cbolangiocarcinoma is an extremely rare condition, it needs to be considered when widespread earcinomatosis accompanies biliary obstruction. Unfortunately, the prognosis of such patients is dismal and palliation'remains the mainstay of therapy. Medline review failed to reveal any reported cases of ovarian metastasis from cholangiocarcinoma, so this likely represents the first such report.
418
t420
THE RISK OF POST E R C P PANCREATITIS W I T H AND WITHOUT SPHINCTEROTOMY IN PATIENTS UNDERGOING BILIARY STENT PLACEMENT. MA Shaft, RM Bashir, FH AI-Kawas, DF Fleischer, SB Benjamin. Deparlment of Medicine, Georgetown University Medical
ARE THE PATENCY RATES FOR 10 FRENCH AND 11.5 FRENCH STENTS DIFFERENT FOR COMMON DUCT OBSTRUCTION AND HILAR OBSTRUCTION? RANDOMIZED, PROSPECTIVE STUDY. h.~..S.ke,~m, G. Lehman, D. Earle, E. I aTsridis, J. Frakes, J. Johanson, T. Qaseem, D. Howell, Indiana University Medical Center, Indianapolis, IN; Rockford GE Associates, Rockford, IL; Maine Medical Center, Portland, ME When used for malignant obstruction of the common duct, expandable metal stents have been shown to have longer patency rates than standard 10 French biliary eadoprostheses (Lancet, 1992;340:1488). The differences in stent patency rates for hilar obstruction are less clear (GI Enclose 1993;39:310A). We postulated that similar findings would be seen when comparing 10 French and 11.5 French stents. METHODS: The study population consists of 212 patients with malignant bile duct obstruction; 46 had hilar and 166 common duct obstruction. Tumor types for the hilar group included bile duct (46%), metastatic (28%), gallbladder (13%), and other (13%). Tumor types for the common duct group included pancreatic (70%), bile duct (15%), metastatic (11%), gallbladder (1%), and other (3%). Following guidewire advancement proximal to the stricture, the patient was randomized to a 10 French or an 11.5 French biliary stent. Patients with hilar and common duct obstruction were randomized separately. Patients were prospectively followed up every l to 2 months to assess for symptoms of stem ocdnsion and to determine the clinical response rate. Stent related interventions and hospital days resulting from stem dysfunction were tallied. The change in total bilirubin between baseline and 30 day post-stenting was compared. The groups were similar with regards to age, minor type, tumor location, and baseline bilirubin. RESULTS: Hilar Common Duct IOF II.SF P 10F II.5F P
Center,Washington D . C .
Background:Endoscopic Sphincterotomy (ES) prior to the placement of biliary stent is frequently performed,hnwever, data evaluating the utility and complications of this approach are limited.Our aim was to compare post ERCP complications in patients who underwent biliary stent insertion with and without ES. Methods:All patients undergoing stem placement from 1989 to 1995 were evaluated.Data collected included patient demographics,procedural indieation,stent size,antecedent endoscopic therapy and ES and stent related complications. Patients with prior biliary sphinterotomy and with pancreatic stents were excluded. Results:Among the 148 patients (76 M, 72 F) who underwent stent placement over a 6 year period 61 patients underwent ES at the time of stent placement, 87 patiems had stent placed without sphincterotomy. The groups were matched for age, sex, procedural indication and stem size. Eight patients (5,4%) had complications requiring hospitalization. There was no procedure related perforation or death. Stem w/F.S. Stem only P value Total patients Complications
n=61
n=87
Bleeding 3(4.9%)" -ns Pancreatitis --2(2.3%) ns Abdominal pain 1(1.6%) 2(2.3%) ns Total 4 4 ns Condusions: There was no statistically significant difference in the rate of complications in patients undergoing biliary stem placement with or without sphinctemtomy . ES at the time of stem placemem does not decrease the risk ofpost ERCP pancreatitis and is not necessary for routine biliary stem placemem.
VOLUME 43, NO. 4, 1996
t.=77)
(,~=st)
BillmbinDecrease(mg/dl) 7.5 10.I .05 9.6 lO.O .87 Stent Sun,lent Days 183 311 .24 115 152 .99 patleat SurvivalDays 142 170 .37 286 184 .86 Stent RelatedHeap.Days 1.6 1:2 .45 1.6 2.9 .30 Stent Relatedlnterventiom .58 .43 .43 .92 .85 .88 S U M M A R Y : 1) A trend for improved patency rates was seen for the 11.5 French stent for conunon duct obstruction. This did not translate into a reduction in the number of stent related interventions and hospital days for stem dysfunction. 2) There was no statistical improvement in the stent patancy rates for 11.5 French stents for hilar obstruction. CONCLUSION: These results suggest that larger stents may be more effective for providing longer periods of drainage in common duct obstruction. This study is ongoing.
GASTROINTESTINAL ENDOSCOPY
395