- Email: [email protected]
interventional radiology procedures in difficult ERCP
~RLP--BILIAR Y 445
"~447
COMBINED ERCP/INTERVENTIONAL RADIOLOGY PROCEDURES IN DIFFICULT ERCP. R McMahon, W Qureshi, S Tep/ick.
PLASTIC-THROUGH-METAL: DO PLASTIC STENTS PROVIDE SATISFACTORY DECOMPRESSION OF OCCLUDED METAL MESH STENTS? JB Mundorf. MK Newcomer, PS lowell, GM Eisen,' MS Branch, J Affronti, S Guarisco, I Leung, PB Cotton, J Baillie, Division of Gastroenterology, Duke University Medical Center, Durham, NC Background: Occluded metal stents are often managed by inserting a plastic stent through the metal stent. Objective: To determine if plastic stents provide satisfactory decompression when inserted through occluded metal mesh stents. Methods: We retrospectively reviewed our database to identify all patients with occluded metal stents treated with plastic stents and reviewed their outcomes. Results: 15 patients (9 female, 6 male, mean age 65) had been treated for metastatic disease (6), pancreatic carcinoma (5), cholangiocarcinoma O) and benign stricture originally believed malignant (1). 6 hilar and 9 non-hilar strictures were palliated with metal stents placed endoscopical[y (13) or pereutaneotisly (2). Stent occlusion resulted from tissue ingrowth (13) or sludge/debris (2). Each occlusion was treated with a single plastic through metal stent. Those that subsequently migrated or became occluded were replaced with another plastic stent or were treated perctuanenusly. 28 plastic stents were placed through metal ones; follow up was available in 27 (5 patients had one stent, 7 had two stents and 3 had three stents). In the 5 patients who received a single stent, 1 stent was removed at 86 days for partial obstruction and 4 stents were functional at the time of death (27-216 days after insertion), The remaining 10 patients received a total of 22 plastic stents; 15 of these occluded or migrated. 13 were replaced with another endoscopic plastic stent and 2 required percutaneous management. The median time to occlusion or migration was 60 days for all stents (range 3-258), 44 days for hilar stents (range 3-249) and 69 days for non-hilar stents (range 4258). Conclusion: Placing a plastic stent through an occluded metal mesh one may ensure continued palliation of malignant biliary obstruction. However, plastic stents are by no means an idea/solution. Our experience of "plastic through metal" stents is that they occlude at a rate similar to plastic stents alone. This differs significantly from previously published data.
Gastroenterology and Radiology, Univ of Arkansas Med Sr Little Rock, AR. PURPOSE AND METHOD: We review two cases showing a rote for ERCP combined with interventionaL radiology. A complication highfig~s and confirms the need for well sequenced technique and continuing cooperation between disciplines. RESULTS: Case I; 82 year old man with obstructive jaundice and common duct stones. ERCP cannulation was unsuccessful. A deep diverticulum was adjacent to the papilla. Radiology placed a percutaneous drain and pigtail steot Two weeks later at ERCP, a papi,otome was guided away from the diverticulum along the axial orientation of the stent and drain. The drain and the stent were removed, Stones and debris were removed from the papillotomy. A single 1 crn stone remained in the common bile duct, and a 7Fr pigtail stent was piacad endoscopically. The patient has done well. Case 2; 74 year o|0 man with obstructive jaundice and art ampullary adenoma (with atypia) which could not be cannulated. The patient refused surgery and radiology placed a percutaneous drain. Two weeks later endoscopy was performed for placement of stent and biopsy. An endoscopic stent was exchanged over a guide wire introduced through the percutaneous drain. The drain was removed before the guide wire. The wire was removed from the duodenal side to maintain sterility. Bile drainage and stent position were confirmed After the procedure, the patient had right upper quadrant pain and a fall in blood volume. A subcapsular hematoma was confirmed by computed tomography. CONCLUSION: A combined procedure allowed safe papil[otomy adjacent to a large diverticulum and effective therapy without surgery in Case 1. Effective internal biliary drainage and extenSive morselization of an adenomatous ampulla was achieved in Case 2. Removal of the guide wire pdor to complete removal of the drain may avoid the complication we encountered.
446
448
DIAGNOSTIC APPROACH TO ADENOMAS OF THE PAPILLA OF VATER BY INTRADUCTAL ULTRASOUND (IDUS) J, Menz.el, E.-Ch. Foerster, W. Domschke Department of Medicine B, University of Mnenster. 48129 Muenster. Germany An adenoma-earcinoma sequence is expected a(so for the adenomatous growth in the papilla of Vater. Therapeutic procedures should be selected on the basis of preoperative evaluation of invasion by various imaging techniques. Endoscopic retrograde cholangio-pancreatography (ERCP) atone is not able to provide any direct information of tissue in filtration. Even endoscopic ultrasound (EUS) is limited in the detection of processes of less than 10 mm in diameter. Ultrasound probes of the size of the pancreatic or the bile-duct system introduced during ERCP promise additional information to achieve the above mentioned aims. Mechanical and electronic probes (Boston Scientific, Endosonics) with diameters of 3.5 F to 6,0 F were inserted through the working channel of a commonly used duodenoscope (Olympus JFIT20). Using a guide wire the probes were inserted into 16 patients with polypoid processes of the papilla of Voter. The sonomorphological pictures where correlated to the histopathological findings and, if available, with the resection specimen. Using frequencies of 12.5 to 30 MHz the pefipapillary tissue can be depicted in lens microscopic dimension. Infiltration of the papilla of Vater by a carcinoma of the pancreatic head appeared in homogenously echopoor whereas benign papillary stenoses are sonographically echorich. The epithelium of normal sized pancreatic ducts is depicted cireumferentially three layered. 8 patients underwent resection of the papilla of Vater. Correlation of the sonographic pictures with the histologiea( cross-sec6ons showed that structures smaller than 1 mm were deteetable. The high frequency of ultrasound gives excellent images in high resolution. But the frequency restricts the depth of penetration. Cable driven probes show a lack of flexibility. However, within a few minutes the probes couM be inserted into the papilla of Voter without prior papi/lotomy. There was no indication of any trauma to the duct system or the pancreas due to the ultrasound probe. Technically, the depth of penetration needs to be increased to allow for full-depth investigation, lmraductal ultrasound (IDUS) of the papilla of Vater which is performed during ERCP may become a complementary diagnostic technique to conventional methods by adding the lens microscopic dimension. This new diagnostic capacity is currently evaluated in a prospective controlled study in comparison to conventional imaging techniques.
C Y S T I C D U C T P A T E N C Y IN C H O L E C Y S T I T I S t A C O M P A R I S O N OF H I D A S C A N N I N G V ~ E N D O S C O P I C RETROGRADE CHOLANGIOGRAPHY (ERCI. JOSEPH
VOLUME 41, NO. 4, 1995
NASH. MD~ SETH A. COHEN, MD, FRANKLIN E. KASMIN, MD, JEROME H. SIEGEL, biD, ST. LUKE'SROOSEVELT HOSPITAL CENTER AND BETH ISRAEL NORTH, NEW YORK, NY Absence of gallbladder visualization on radionuclide hepatobiliary scanning (HIDA) is taken to be the gold standard of cystic duct obstruction and acute cholecystitis. Goal: i) To compare the incidence of gallbladder (GB) visualization with ERC in patients (PTS) believed to have acute cholecystitis and nonvisualization of the GB on HIDA and 2) determine if this finding has any clinical significance. Methods: Records were retrospectively reviewed to select patients with non-visualization of the GB on HIDA who also had pre-operative ERC~ Operative and pathology reports were examined. Results: Ten PTS were identified who had nonvisualization of GB on HIDA. ERC visualized the GB in 5 PTS demonstrating cystic duct patency: pathology in these patients showed only chronic inflammation. In the remaining 5 PTS, GB was not visualized on ERC demonstrating complete cystic duct obstruction: pathology in these patients revealed gangrenous cholecystitis in 3 PTS (i with local perforation) hydrops with marked edema of the gallbladder wall in 1 patient and acute inflammation in i patient (P=0.038). Conclusion: i) Cystic duct obstruction on HIDA scanning has a 50% specificity compared to ERC 2) PTS with cystic duct obstruction at ERC are significantly more/likely to have more severe cholecystitis, with possible gangrene and perforation, compared to PTS with cystic duct patency.
GASTROINTESTINAL ENDOSCOPY
407
"~447
COMBINED ERCP/INTERVENTIONAL RADIOLOGY PROCEDURES IN DIFFICULT ERCP. R McMahon, W Qureshi, S Tep/ick.
PLASTIC-THROUGH-METAL: DO PLASTIC STENTS PROVIDE SATISFACTORY DECOMPRESSION OF OCCLUDED METAL MESH STENTS? JB Mundorf. MK Newcomer, PS lowell, GM Eisen,' MS Branch, J Affronti, S Guarisco, I Leung, PB Cotton, J Baillie, Division of Gastroenterology, Duke University Medical Center, Durham, NC Background: Occluded metal stents are often managed by inserting a plastic stent through the metal stent. Objective: To determine if plastic stents provide satisfactory decompression when inserted through occluded metal mesh stents. Methods: We retrospectively reviewed our database to identify all patients with occluded metal stents treated with plastic stents and reviewed their outcomes. Results: 15 patients (9 female, 6 male, mean age 65) had been treated for metastatic disease (6), pancreatic carcinoma (5), cholangiocarcinoma O) and benign stricture originally believed malignant (1). 6 hilar and 9 non-hilar strictures were palliated with metal stents placed endoscopical[y (13) or pereutaneotisly (2). Stent occlusion resulted from tissue ingrowth (13) or sludge/debris (2). Each occlusion was treated with a single plastic through metal stent. Those that subsequently migrated or became occluded were replaced with another plastic stent or were treated perctuanenusly. 28 plastic stents were placed through metal ones; follow up was available in 27 (5 patients had one stent, 7 had two stents and 3 had three stents). In the 5 patients who received a single stent, 1 stent was removed at 86 days for partial obstruction and 4 stents were functional at the time of death (27-216 days after insertion), The remaining 10 patients received a total of 22 plastic stents; 15 of these occluded or migrated. 13 were replaced with another endoscopic plastic stent and 2 required percutaneous management. The median time to occlusion or migration was 60 days for all stents (range 3-258), 44 days for hilar stents (range 3-249) and 69 days for non-hilar stents (range 4258). Conclusion: Placing a plastic stent through an occluded metal mesh one may ensure continued palliation of malignant biliary obstruction. However, plastic stents are by no means an idea/solution. Our experience of "plastic through metal" stents is that they occlude at a rate similar to plastic stents alone. This differs significantly from previously published data.
Gastroenterology and Radiology, Univ of Arkansas Med Sr Little Rock, AR. PURPOSE AND METHOD: We review two cases showing a rote for ERCP combined with interventionaL radiology. A complication highfig~s and confirms the need for well sequenced technique and continuing cooperation between disciplines. RESULTS: Case I; 82 year old man with obstructive jaundice and common duct stones. ERCP cannulation was unsuccessful. A deep diverticulum was adjacent to the papilla. Radiology placed a percutaneous drain and pigtail steot Two weeks later at ERCP, a papi,otome was guided away from the diverticulum along the axial orientation of the stent and drain. The drain and the stent were removed, Stones and debris were removed from the papillotomy. A single 1 crn stone remained in the common bile duct, and a 7Fr pigtail stent was piacad endoscopically. The patient has done well. Case 2; 74 year o|0 man with obstructive jaundice and art ampullary adenoma (with atypia) which could not be cannulated. The patient refused surgery and radiology placed a percutaneous drain. Two weeks later endoscopy was performed for placement of stent and biopsy. An endoscopic stent was exchanged over a guide wire introduced through the percutaneous drain. The drain was removed before the guide wire. The wire was removed from the duodenal side to maintain sterility. Bile drainage and stent position were confirmed After the procedure, the patient had right upper quadrant pain and a fall in blood volume. A subcapsular hematoma was confirmed by computed tomography. CONCLUSION: A combined procedure allowed safe papil[otomy adjacent to a large diverticulum and effective therapy without surgery in Case 1. Effective internal biliary drainage and extenSive morselization of an adenomatous ampulla was achieved in Case 2. Removal of the guide wire pdor to complete removal of the drain may avoid the complication we encountered.
446
448
DIAGNOSTIC APPROACH TO ADENOMAS OF THE PAPILLA OF VATER BY INTRADUCTAL ULTRASOUND (IDUS) J, Menz.el, E.-Ch. Foerster, W. Domschke Department of Medicine B, University of Mnenster. 48129 Muenster. Germany An adenoma-earcinoma sequence is expected a(so for the adenomatous growth in the papilla of Vater. Therapeutic procedures should be selected on the basis of preoperative evaluation of invasion by various imaging techniques. Endoscopic retrograde cholangio-pancreatography (ERCP) atone is not able to provide any direct information of tissue in filtration. Even endoscopic ultrasound (EUS) is limited in the detection of processes of less than 10 mm in diameter. Ultrasound probes of the size of the pancreatic or the bile-duct system introduced during ERCP promise additional information to achieve the above mentioned aims. Mechanical and electronic probes (Boston Scientific, Endosonics) with diameters of 3.5 F to 6,0 F were inserted through the working channel of a commonly used duodenoscope (Olympus JFIT20). Using a guide wire the probes were inserted into 16 patients with polypoid processes of the papilla of Voter. The sonomorphological pictures where correlated to the histopathological findings and, if available, with the resection specimen. Using frequencies of 12.5 to 30 MHz the pefipapillary tissue can be depicted in lens microscopic dimension. Infiltration of the papilla of Vater by a carcinoma of the pancreatic head appeared in homogenously echopoor whereas benign papillary stenoses are sonographically echorich. The epithelium of normal sized pancreatic ducts is depicted cireumferentially three layered. 8 patients underwent resection of the papilla of Vater. Correlation of the sonographic pictures with the histologiea( cross-sec6ons showed that structures smaller than 1 mm were deteetable. The high frequency of ultrasound gives excellent images in high resolution. But the frequency restricts the depth of penetration. Cable driven probes show a lack of flexibility. However, within a few minutes the probes couM be inserted into the papilla of Voter without prior papi/lotomy. There was no indication of any trauma to the duct system or the pancreas due to the ultrasound probe. Technically, the depth of penetration needs to be increased to allow for full-depth investigation, lmraductal ultrasound (IDUS) of the papilla of Vater which is performed during ERCP may become a complementary diagnostic technique to conventional methods by adding the lens microscopic dimension. This new diagnostic capacity is currently evaluated in a prospective controlled study in comparison to conventional imaging techniques.
C Y S T I C D U C T P A T E N C Y IN C H O L E C Y S T I T I S t A C O M P A R I S O N OF H I D A S C A N N I N G V ~ E N D O S C O P I C RETROGRADE CHOLANGIOGRAPHY (ERCI. JOSEPH
VOLUME 41, NO. 4, 1995
NASH. MD~ SETH A. COHEN, MD, FRANKLIN E. KASMIN, MD, JEROME H. SIEGEL, biD, ST. LUKE'SROOSEVELT HOSPITAL CENTER AND BETH ISRAEL NORTH, NEW YORK, NY Absence of gallbladder visualization on radionuclide hepatobiliary scanning (HIDA) is taken to be the gold standard of cystic duct obstruction and acute cholecystitis. Goal: i) To compare the incidence of gallbladder (GB) visualization with ERC in patients (PTS) believed to have acute cholecystitis and nonvisualization of the GB on HIDA and 2) determine if this finding has any clinical significance. Methods: Records were retrospectively reviewed to select patients with non-visualization of the GB on HIDA who also had pre-operative ERC~ Operative and pathology reports were examined. Results: Ten PTS were identified who had nonvisualization of GB on HIDA. ERC visualized the GB in 5 PTS demonstrating cystic duct patency: pathology in these patients showed only chronic inflammation. In the remaining 5 PTS, GB was not visualized on ERC demonstrating complete cystic duct obstruction: pathology in these patients revealed gangrenous cholecystitis in 3 PTS (i with local perforation) hydrops with marked edema of the gallbladder wall in 1 patient and acute inflammation in i patient (P=0.038). Conclusion: i) Cystic duct obstruction on HIDA scanning has a 50% specificity compared to ERC 2) PTS with cystic duct obstruction at ERC are significantly more/likely to have more severe cholecystitis, with possible gangrene and perforation, compared to PTS with cystic duct patency.
GASTROINTESTINAL ENDOSCOPY
407