Endoscopic decompression and drainage of benign and malignant biliary obstruction

Endoscopic decompression and drainage of benign and malignant biliary obstruction

0016-5107/82/2802-0079$02.00/0 GASTROINTESTINAL ENDOSCOPY Copyright © 1982 by the American Society for Gastrointestinal Endoscopy Endoscopic decompre...

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0016-5107/82/2802-0079$02.00/0 GASTROINTESTINAL ENDOSCOPY Copyright © 1982 by the American Society for Gastrointestinal Endoscopy

Endoscopic decompression and drainage of benign and malignant biliary obstruction Jerome H. Siegel, MD G. Thomas Harding, MD Frank Chateau, PA-C Bronx, New York New York, New York

Successful performance of endoscopic sphincterotomy in the treatment of choledocholithiasis led to the placement of retrograde, transpapillary catheters for internal drainage and prevention of cholangitis. This technique presented the opportunity for using nasobiliary tubes for short term treatment of this problem or placing a permanent drain into the bile duct for long term management. Internal drains placed endoscopically have been used on 15 occasions: 10 nasobiliary and five permanent. These drains have functioned well without complications prompting us to recommend this approach in patients with benign or malignant obstruction of the biliary tree. Nonoperative percutaneous decompression of an obstructed biliary tree due to either benign or malignant conditions has been recently described and utilized in several centers. 1 - 4 This technique requires the antegrade insertion of needles, guide wires, and catheters through the liver parenchyma into the biliary radicals with final placement of a drainage catheter. The catheter is passed beyond the site of obstruction, if possible, into the duodenum providing both decompression and internal drainage, a combination which reestablishes bile flow to the intestine with restoration of physiological function. Transpapillary endoscopic retrograde placement of internal drains across the duodenum into the biliary tree was initially developed for short term management of stone disease. It soon became evident that long term management of both benign and malignant diseases was possible using this technique with modifications. 5 - 7 Two types of drains are currently utilized: (1) transnasal for temporary use, and (2) internal stents, which are left for an indefinite period. We have had the opportunity of placing ten temporary and five permanent drains endoscopically in patients with benign and malignant obstruction of the biliary tree, and we offer this technique as an alternative to the percutaneous approach.

From the Section of the Liver Diseases, Veterans Administration Medical Center, Bronx, New York, and the Division of Gastroenterology, Beth Israel Medical Center, Mount Sinai School of Medicine City University of New York, New York. ' Reprints requests: Jerome H. Siegel, MD, 230 East 69th Street, New York, New York 10021. VOLUME 28, NO.2, 1982

METHODS Nasobiliary drains (transnasal) After obtaining informed consent for endoscopic retrograde cholangiopancreatography (ERCP) and duodenoscopic sphincterotomy, a diagnostic ERCP is performed in the usual manner. After confirmation of obstruction to the biliary tree, a duodenoscopic sphincterotomy may be performed. The nasobiliary catheter (NBC) EBD-1 (Cook Catheter Corp., Bloomington, Ind.) (Fig. 1) is prepared for insertion through the endoscope. Insertion is accomplished as follows: A spring guide wire measuring 480 cm in length is advanced through the cannula and into the bile duct through the intact papilla or sphincterotomy (Fig. 2). The cannula is then removed over the wire, and the catheter, pigtail end first, is advanced over the guide wire into the bile duct. After confirming the position of the catheter, the guide wire is removed while firmly holding the catheter in position. The endoscope is then slowly withdrawn from the duodenum while the catheter is advanced a distance equal to that of the withdrawn endoscope. The catheter position is confirmed fluoroscopically as the endoscope is removed maintaining a configuration which conforms to the greater curvature of the stomach looping into the duodenum and the bile duct. Once the endoscope is removed from the patient, a check of the position of the catheter is made once again by injecting contrast material (Fig. 3). The NBC is threaded into a feeding tube previously inserted through a nasal passage and brought out through the mouth. The feeding tube is withdrawn leaving the NBC in position. The NBC is 79

Figure 1. Elements of a nasobiliary tube showing tubing with a distal pigtail (left) and a coil spring guide wire (right).

Figure 2. Radiograph showing placement of a guide wire

into the common bile duct.

held in position in the bile ducts by the 1-cm pigtail at the end. The tube can be comfortably attached to the patient's forehead or gown and attached to the biliary drainage bag system which functions by gravity drainage. 80

Figure 3. Cholangiogram after the endoscope has been re-

moved illustrating placement of the tube into the bile duct. Contrast has been injected from the proximal portion of the catheter. GASTROINTESTINAL ENDOSCOPY

DISCUSSION

Internal stents The procedure for insertion of duodenal biliary catheters is similar to that for NBCs. The pigtail catheter is 15 cm long and has an internal diameter of 1.4 mm and an external diameter of 1.6 mm. The proximal catheter measures 285 cm (Medizin-Technische Werkstatte, Buderich, West Germany) (Fig. 4). After passing a guide wire through a cannula, which has been inserted into the bile duct through either an intact papilla or a sphincterotomy, and removing the cannula, the pigtail catheter is then passed over the wire. The proximal segment is passed onto the wire functioning as a pusher to advance the internal drain into the bile duct. Fluoroscopic confirmation of the position of the catheter is made, and once the drain is in place, the guide wire is slowly withdrawn until the proximal end of the internal drain lies free in the duodenum. Confirmation of the position of the catheter in the bile cut may require the insertion of a diagnostic cannula for injection of contrast material into the bile duct.

RESULTS Endoscopic drains have been placed on 15 occasions (10 nasobiliary and five permanent). All were successfully placed without complication. The nasobiliary catheters, eight for benign disease and two for malignant disease, were left in place for decompression for periods of 3 to 12 days functioning by gravity drainage. The permanent internal drains, three placed for malignancy and two for retained stones, have functioned for 1 to 11 months without clinical or biochemical evidence of recurrent obstruction. Cholangitis has not occurred with either tube, and antibiotics have been discontinued after placement of the catheters.

Nonsurgical decompression of an obstructed biliary tree includes two methods currently in use: the transhepatic percutaneous technique and endoscopic transpapillary retrograde insertion. The percutaneous method requires the transhepatic placement of needles, wires, and catheters advanced through the skin, liver capsule and parenchyma, and vascular components before entry into the biliary radicles. This route ultimately provides antegrade cannulation of the biliary ducts with subsequent decompression and drainage of bile. With this method tubes or catheters exit through the liver and skin to the external environment presenting potential problems which require meticulous attention and care to avoid bacterial contamination, trauma, and accidental extubation. Subsequent complications include local infection, sepsis, pneumothorax, hemorrhage, and intraabdominal leaks-important considerations when placing these drains. Endoscopic drains avoid the potential complications cited above as they are placed internally crossing the duodenum. These transpapillary drains usually restore physiological integrity of bile flow while decompressing an obstructed system. Assessment of decompression or sequential follow-up of stone passage is provided by injecting contrast material through the NBC under fluoroscopic control. Drug profusion for stone dissolution is a real possibility.8 In some cases, morbidity is reduced by placement of a drain through an intact papilla avoiding sphincterotomy. The options available to the clinician include the immediate short term management of benign or malignant disease by placement of an NBC or long term management with a duodenal biliary catheter. When

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Figure 4. Photograph of a permanent type stent demonstrating a separate distal segment which is left in place. VOLUME 28, NO.2, 1982

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considering placement of biliary drains in the palliative treatment of malignancy or therapeutic treatment of benign disease, we suggest the endoscopic approach which offers an advantage of safety that eliminates the need for external hardware and its attendant problems. REFERENCES 1. BURCHANTH F: A new endoprosthesis for non-operative intubation of the biliary tract in malignant obstructive jaundice. Surg Gynecol Obstet 146:78, 1978 2. NAKAYAMA T, IKEDA A, OKUDA K: Percutaneous transhepatic drainage of the biliary tract: technique and results in 104 cases. Gastroenterology 74:554, 1978 3. PERIERAS RV JR, RHEINGOLD OJ, HUTSON D, MEJIA j, VIAMONTE M, CHIPRUT RD, SCHIFF ER: Relief of malignant obstructive jaundice

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by percutaneous insertion of a permanent prosthesis in the biliary tree. Ann Intern Med 89:589, 1978 RING Ej, OLEAGA lA, FEINMAN DB, HUSTED IW, LUNDERQUIST A: Therapeutic application of catheter cholangiography. Radiology 128:333, 1978 COTTON PB, BURNEY PG, MASON RR: Transnasal bile duct catheterization after endoscopic sphincterotomy: method for biliary drainage, perfusion and sequential cholangiography. Gut 20:285, 1979 SOEHENDRA N, REYNDERS-FREDERIX V: Palliative bile duct drainage-a new endoscopic method of introducing a transpapillary drain. Endoscopy 12:8, 1980 SIEGEL JH, HARDING GT, CHATEAU F: Endoscopic decompression of the obstructed biliary tree: transduodenal placement of stents. Gastroenterology 80:1285, 1981 WITZEl L, WIEDERHOLT j, WOLBERGS E: Dissolution of retained duct stones by perfusion with monooctanoin via a Teflon catheter introduced endoscopically. Gastrointest Endosc 27:63, 1981

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