- Email: [email protected]
CATHETER AND WIRE GUIDED ENDOSCOPE EXCHANGE FOR BILIARY STENTS
542
prostaglandin synthetase inhibitors have been suspected of having a dual mode of action, and no effect was found for acetylsalicyclic acid. Furthermore, preliminary investigation of other prostaglandin synthetase inhibitors has shown no receptor antagonism. The dual effect of fenamates on prostaglandin synthesis and binding may be of therapeutic importance for the treatment of menorrhagia, because studies where prostaglandin levels were examined in endometrium after mefenamic acid ingestion show reduction but not complete abolition.8 The additional inhibition of binding may therefore contribute to their efficacy. Other clinical uses for receptor inhibition by fenamates
may
include
treatment
of
uterine
hyperstimulation provoked by exogenous PGE (in therapeutic abortion, or induction of labour), or of afterpains where there is uterine hypersensitivity to prostaglandins.9 Other prostanoids such as prostacyclin (PG 12) have been implicated in menorrhagia and elucidation of the effect of fenamates on PG 12 receptor binding, the precise inhibitory mechanism of fenamates on PGE receptor binding, and the effect of fenamates on other uterine eicosanoid receptors may lead to more effective treatment of these conditions.
Methods and Devices
CATHETER AND WIRE GUIDED ENDOSCOPE EXCHANGE FOR BILIARY STENTS
M. C. P. R. is
a
Parke Davts Medical Research Fellow; A. L. B. is R. C.-S. was
supported by Action Research for the Crippled Child; supported by Sterling Winthrop. Correspondence should be addressed to M. C. P. R. REFERENCES
AC, Rees MCP Mefenamic acid in the treatment of gynecologic disorders. In: Tumbull AC, ed. A retrospective review of clinical expenence Amsterdam Excerpta Medica, 1987 1-17. 2. Sanger GJ, Bennett A. Fenamates may antagonise the actions of prostaglandin endoperoxides in human myometrium. Br J Clin Pharmacol 1979; 4: 479-84 3. McClean JR, Gluckman MI. On the mechanism of the pharmacologic activity of meclofenamate sodium. Arzneimittelforschung 1983; 33: 627-32. 4. Adelantado JM, Rees MCP, Lopez Bernal A, Tumbull AC Increased uterine prostaglandin E receptors in menorrhagic women. Br J Obstet Gynaecol 1988, 95: 162-65. 5. Adelantado JM, Humphries J, Lopez Bernal A, Tumbull AC Is there a topographical distribution of prostaglandin E2 receptors in the human pregnant uterus? In: Jones CT, Nathanielsz PW, eds. The physiological development of the fetus and newborn. London Academic Press, 1985 489-92 6. Adelantado JM Hormonal studies in reproductive tissues a receptor approach [MSc Thesis]. Oxford: University of Oxford, 1985 7. Smith RP. The dynamics of nonsteroidal antiinflammatory therapy for primary dysmenorrhea. Obstet Gynecol 1987; 70: 785-88. 8. Fraser IS. The treatment of menorrhagia with mefenamic acid. Res Clin Forums 1983, 5: 93-99. 9. Keirse MJNC Plenary lecture to First European Congress on Prostaglandins in Reproduction In. Husslein P, ed Pregnancy and parturition Vienna Facultas Universitatsverlag, 1988. 9-10. 10. Smith SK, Kelly RW, Abel MH, Baird DT A role for prostacyclin (PGI2) in excessive menstrual bleeding. Lancet 1981; i: 522-24 1. Tumbull
French pigtail per-nasal catheter. The guidewire is fractionally withdrawn so that the pigtail forms (fig 2) and anchors the catheter. The endoscope is then withdrawn under fluoroscopic control, and the guidewire and catheter are left in position (fig 3). Endoscopic biopsy forceps are passed down the biopsy channel of a large-
D. F. MARTIN
Department of Radiology and Gastroenterology Unit, University Hospital of South Manchester, Withington, Manchester M20 8LR ENDOSCOPIC insertion of a biliary stent for malignant obstructive jaundice requires an endoscope with a biopsy-channel diameter of at least 3-7 mm, to accommodate a 10 French stent. Diagnostic cholangiography is usually done with a narrow-channel instrument (2-8 mm), therefore exchange for a large-channel instrument is necessary for stent insertion. After successful cannulation of the
papilla and negotiation of the malignant obstruction for diagnostic cholangiography, the endoscopist is reluctant to remove the cannula because of possible difficulties in repeat cannulation with a less manoeuvrable, large-channel instrument, which can lead to failure of stent insertion in about 5% of patients. Endoscopic sphincterotomy by a wire-guided sphincterotome can improve access to the bileducts, but is not essential for insertion of a 10 or 115French stent, and increases the risk of the procedure. I describe here a simple technique for endoscope exchange over a guidewire and catheter, without loss of access to the bileduct above the tumour and without the need for sphincterotomy.
Technique
Diagnostic cholangiography is done with a 2-8 mm channel (Olympus JF1T10 or equivalent) and an endoscopic retrograde cholangiopancreatography (ERCP) cannula through which a 0-038 in guidewire can be inserted (fig 1). After cholangiography, the stilette of the cannula is removed and a 3-5 m long, 0-038 in ’Teflon’-coated guidewire is inserted through the cannula and positioned above the obstruction. The ERCP cannula is removed, with the guidewire left in position, and is replaced by a 6
instrument
Fig 1-Cannufation with small-channel endoscope.
543
Fig 4-Insertion of stent through largechannel endoscope.
Fig 2-Withdrawal of guidewire to form pigtail. e
channel
endoscope (Olympus TJF10 or equivalent) and the guidewire is grasped by the forceps. The guidewire and catheter are fed up the biopsy channel and through the biopsy port by withdrawal of the biopsy forceps. Under fluoroscopic control, the large-channel endoscope is inserted into the duodenum, and the per-nasal catheter and guidewire are withdrawn through the endoscope during its onward passage to prevent loop formation and to maintain their position within the bileducts. With the endoscope satisfactorily positioned in the duodenum, a 10 or 11-5 French straight stent can be passed over the per-nasal catheter and positioned across the malignant stricture within the bileduct (fig 4). The guidewire is withdrawn and a cholangiogram is performed via the per-nasal catheter to ensure a satisfactory stent position and the per-nasal catheter is then withdrawn, followed by the endoscope. Comment
Fig 3—Withdrawal of small-channel endoscope with guidewire and catheter left in position.
12 patients have been treated in this way with immediate success in 11. All had malignant, inoperable, common bileduct obstruction. Successful cannulation of the papilla and negotiation of the malignant stricture had been accomplished with the small-channel endoscope, but often with difficulty due to distortion of the distal bileducts by pancreatic tumour. Removal of the catheter to exchange endoscopes would have entailed a high risk of failed recannulation. In the 1 patient (early in the series) in whom the procedure failed, the guidewire and catheter slipped from the common duct because a loop of per-nasal catheter was allowed to form in the stomach during insertion of the large-channel instrument. Careful fluoroscopy and the avoidance of loops in subsequent patients has prevented a recurrence of this. The described technique allows rapid exchange of a narrowchannel for a large-channel endoscope, and is simple, safe, effective, and uses readily available materials. The technique allows placement of a biliary stent after diagnostic cholangiography as a single procedure, and avoids the increased risk of unnecessary
endoscopic sphincterotomy.
prostaglandin synthetase inhibitors have been suspected of having a dual mode of action, and no effect was found for acetylsalicyclic acid. Furthermore, preliminary investigation of other prostaglandin synthetase inhibitors has shown no receptor antagonism. The dual effect of fenamates on prostaglandin synthesis and binding may be of therapeutic importance for the treatment of menorrhagia, because studies where prostaglandin levels were examined in endometrium after mefenamic acid ingestion show reduction but not complete abolition.8 The additional inhibition of binding may therefore contribute to their efficacy. Other clinical uses for receptor inhibition by fenamates
may
include
treatment
of
uterine
hyperstimulation provoked by exogenous PGE (in therapeutic abortion, or induction of labour), or of afterpains where there is uterine hypersensitivity to prostaglandins.9 Other prostanoids such as prostacyclin (PG 12) have been implicated in menorrhagia and elucidation of the effect of fenamates on PG 12 receptor binding, the precise inhibitory mechanism of fenamates on PGE receptor binding, and the effect of fenamates on other uterine eicosanoid receptors may lead to more effective treatment of these conditions.
Methods and Devices
CATHETER AND WIRE GUIDED ENDOSCOPE EXCHANGE FOR BILIARY STENTS
M. C. P. R. is
a
Parke Davts Medical Research Fellow; A. L. B. is R. C.-S. was
supported by Action Research for the Crippled Child; supported by Sterling Winthrop. Correspondence should be addressed to M. C. P. R. REFERENCES
AC, Rees MCP Mefenamic acid in the treatment of gynecologic disorders. In: Tumbull AC, ed. A retrospective review of clinical expenence Amsterdam Excerpta Medica, 1987 1-17. 2. Sanger GJ, Bennett A. Fenamates may antagonise the actions of prostaglandin endoperoxides in human myometrium. Br J Clin Pharmacol 1979; 4: 479-84 3. McClean JR, Gluckman MI. On the mechanism of the pharmacologic activity of meclofenamate sodium. Arzneimittelforschung 1983; 33: 627-32. 4. Adelantado JM, Rees MCP, Lopez Bernal A, Tumbull AC Increased uterine prostaglandin E receptors in menorrhagic women. Br J Obstet Gynaecol 1988, 95: 162-65. 5. Adelantado JM, Humphries J, Lopez Bernal A, Tumbull AC Is there a topographical distribution of prostaglandin E2 receptors in the human pregnant uterus? In: Jones CT, Nathanielsz PW, eds. The physiological development of the fetus and newborn. London Academic Press, 1985 489-92 6. Adelantado JM Hormonal studies in reproductive tissues a receptor approach [MSc Thesis]. Oxford: University of Oxford, 1985 7. Smith RP. The dynamics of nonsteroidal antiinflammatory therapy for primary dysmenorrhea. Obstet Gynecol 1987; 70: 785-88. 8. Fraser IS. The treatment of menorrhagia with mefenamic acid. Res Clin Forums 1983, 5: 93-99. 9. Keirse MJNC Plenary lecture to First European Congress on Prostaglandins in Reproduction In. Husslein P, ed Pregnancy and parturition Vienna Facultas Universitatsverlag, 1988. 9-10. 10. Smith SK, Kelly RW, Abel MH, Baird DT A role for prostacyclin (PGI2) in excessive menstrual bleeding. Lancet 1981; i: 522-24 1. Tumbull
French pigtail per-nasal catheter. The guidewire is fractionally withdrawn so that the pigtail forms (fig 2) and anchors the catheter. The endoscope is then withdrawn under fluoroscopic control, and the guidewire and catheter are left in position (fig 3). Endoscopic biopsy forceps are passed down the biopsy channel of a large-
D. F. MARTIN
Department of Radiology and Gastroenterology Unit, University Hospital of South Manchester, Withington, Manchester M20 8LR ENDOSCOPIC insertion of a biliary stent for malignant obstructive jaundice requires an endoscope with a biopsy-channel diameter of at least 3-7 mm, to accommodate a 10 French stent. Diagnostic cholangiography is usually done with a narrow-channel instrument (2-8 mm), therefore exchange for a large-channel instrument is necessary for stent insertion. After successful cannulation of the
papilla and negotiation of the malignant obstruction for diagnostic cholangiography, the endoscopist is reluctant to remove the cannula because of possible difficulties in repeat cannulation with a less manoeuvrable, large-channel instrument, which can lead to failure of stent insertion in about 5% of patients. Endoscopic sphincterotomy by a wire-guided sphincterotome can improve access to the bileducts, but is not essential for insertion of a 10 or 115French stent, and increases the risk of the procedure. I describe here a simple technique for endoscope exchange over a guidewire and catheter, without loss of access to the bileduct above the tumour and without the need for sphincterotomy.
Technique
Diagnostic cholangiography is done with a 2-8 mm channel (Olympus JF1T10 or equivalent) and an endoscopic retrograde cholangiopancreatography (ERCP) cannula through which a 0-038 in guidewire can be inserted (fig 1). After cholangiography, the stilette of the cannula is removed and a 3-5 m long, 0-038 in ’Teflon’-coated guidewire is inserted through the cannula and positioned above the obstruction. The ERCP cannula is removed, with the guidewire left in position, and is replaced by a 6
instrument
Fig 1-Cannufation with small-channel endoscope.
543
Fig 4-Insertion of stent through largechannel endoscope.
Fig 2-Withdrawal of guidewire to form pigtail. e
channel
endoscope (Olympus TJF10 or equivalent) and the guidewire is grasped by the forceps. The guidewire and catheter are fed up the biopsy channel and through the biopsy port by withdrawal of the biopsy forceps. Under fluoroscopic control, the large-channel endoscope is inserted into the duodenum, and the per-nasal catheter and guidewire are withdrawn through the endoscope during its onward passage to prevent loop formation and to maintain their position within the bileducts. With the endoscope satisfactorily positioned in the duodenum, a 10 or 11-5 French straight stent can be passed over the per-nasal catheter and positioned across the malignant stricture within the bileduct (fig 4). The guidewire is withdrawn and a cholangiogram is performed via the per-nasal catheter to ensure a satisfactory stent position and the per-nasal catheter is then withdrawn, followed by the endoscope. Comment
Fig 3—Withdrawal of small-channel endoscope with guidewire and catheter left in position.
12 patients have been treated in this way with immediate success in 11. All had malignant, inoperable, common bileduct obstruction. Successful cannulation of the papilla and negotiation of the malignant stricture had been accomplished with the small-channel endoscope, but often with difficulty due to distortion of the distal bileducts by pancreatic tumour. Removal of the catheter to exchange endoscopes would have entailed a high risk of failed recannulation. In the 1 patient (early in the series) in whom the procedure failed, the guidewire and catheter slipped from the common duct because a loop of per-nasal catheter was allowed to form in the stomach during insertion of the large-channel instrument. Careful fluoroscopy and the avoidance of loops in subsequent patients has prevented a recurrence of this. The described technique allows rapid exchange of a narrowchannel for a large-channel endoscope, and is simple, safe, effective, and uses readily available materials. The technique allows placement of a biliary stent after diagnostic cholangiography as a single procedure, and avoids the increased risk of unnecessary
endoscopic sphincterotomy.