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Endoscopic removal of biliary stent impacted in the duodenal wall
dure had been gentle and without any other obvious trauma. Despite his poor medical condition, it was decided to perform a laparotomy later the same day. A perforation was shown just beyond the anastomotic site, which was repaired. A T tube was inserted into the common bile duct. After a complicated course he was eventually discharged from the hospital 7 weeks after presentation. He remains well after 3 months of follow-up. Over the period 1986 to 1992, we have performed 1369 ERCPs, with a success rate of cannulating the desired duct of greater than 90 %. Of these examinations, 26 were performed on patients with Billroth II partial gastrectomies, with a cannulating success rate of 42% (11 of 26). The pancreatic duct was cannulated in all 11 cases, whereas the biliary system was cannulated in 9. In 10 of 27 patients no papilla could be identified (in 8 of whom the afferent loop could not be entered). In view of previous reports of perforations and the difficulty of performing sphincterotomy in the presence of this operative appearance 4,5 despite the development of specially designed equipment for cannulation and . I gastrec t omy,' 6 7 I't sphincterotomy after Billroth II partla has been our policy not to persist beyond 1 hour in these cases but to seek an alternate investigative or therapeutic technique. It has been suggested that ERCP in Billroth II patients carries no greater risk or difficulty than in non-operated patients. 1 However, even in that report one fatal duodenal perforation occurred from a diagnostic ERCP. Recently, Onken et al. 8 reported, in abstract form, three perforations in Billroth II patients, and A.R.W. Hatfield (personal communication) reported two perforations in 70 Billroth II patients over a 9-year period. In an early multicenter report of ERCP, duodenal perforation was also more frequent in cases of Billroth II partial gastrectomy. 3 We conclude that, although in skilled hands diagnostic and therapeutic ERCP can sometimes be successfully performed in the presence of a Billroth II partial gastrectomy, success is unpredictable and the advice of Forbes and Cotton2 in 1984, that other methods should be considered, remains valid. In our two cases perforation was recognized early, and early operative repair was undertaken. This early repair led to a successful outcome in both cases, although both patients were severely debilitated because of age or intercurrent disease. We recommend, therefore, that early repair of intestinal perforation after ERCP be undertaken where possible. Mark Lawrence Wilkinson, BSc, MD, FRCP Jeffrey Lionel Engelman, MBBS, FRACP Peter John Vincent Hanson, MA, MRCP, MD GI Unit, Guy's Campus United Medical and Dental Schools of Guy's and St. Thomas's Hospitals London, United Kingdom
REFERENCES 1. Osnes M, Rosseland AR, Aabakken L. Endoscopic retrograde
cholangiography and endoscopic papillotomy in patients with a previous Billroth II resection. Gut 1986;27:1193-8. 2. Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut 1984;25:971-4. 3. Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP): a study of 10,000 cases. Gastroenterology 1976;70:314-20.
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4. Thon RJ, Loffier A, Buess G, Gheorghiu T. Is ERCP a reasonable diagnostic method for excluding pancreatic and hepatobiliary disease in patients with a Billroth II resection? Endoscopy 1983;15:93-5. 5. Safrany L, Neuhaus B, Porto-Carrero G, Krause S. Endoscopic sphincterotomy in patients with Billroth II gastrectomy. Endoscopy 1980;12:16-22. 6. Siegel JR, Yatto RP. ERCP and endoscopic papillotomy in patients with a Billroth II gastrectomy: report of a method. Gastrointest Endosc 1983;29:116-8. 7. Staritz M, Baas U, Ewe K, Meyer-zum-Buschenfelde KH. ERCP using a special catheter with external steering: a reliable aid in typical ERCP problems. Endoscopy 1985;17:26-8. 8. Onken J, Baillie J, Affronti JP, et al. ERCP in patients following Billroth II gastrectomy: is it tougher and riskier than "ordinary" ERCP? [Abstract] Gastrointest Endosc 1992;38:257.
Endoscopic removal of biliary stent impacted in the duodenal wall To the Editor: A 74-year-old woman with metastatic colon cancer presented approximately 7 months ago with obstructive jaundice. A CT scan demonstrated almost complete replacement of the right lobe of the liver with tumor. The left lobe was involved but less so. An ERCP revealed a complex highgrade hilar stricture (type 3). The right intrahepatic biliary ductal system could not be entered. The left system could be entered only with the use of guide wires, and the resultant cholangiogram revealed a high-grade obstruction at the hilum, a second partial obstruction higher up in the left intrahepatic ductal system, and gross dilation above that stricture. A 12-cm-Iong 11.5F Wilson-Cook Cotton-Leung biliary stent (Wilson-Cook, Winston-Salem, N.C.) was then placed, with excellent palliative results. The patient has, however, required stent replacement every 2 to 3 months because of stent occlusion from both sludge and continued tumor growth. Recently, the patient presented with recurrent jaundice. An ERCP with the Olympus T JF -100 therapeutic video duodenoscope (Olympus America Inc., Lake Success, N.Y.) demonstrated a distally migrated stent that was buried in the duodenal wall opposite the ampulla. Multiple attempts were made to retrieve the stent with a polypectomy snare. Attempts to manipulate the snare between the mucosa and the stent tip and attempts to remove the stent by ensnaring the external side flap were unsuccessful. Attempts to retrieve the snare by a variety of biopsy forceps including pelican, rat tooth, and large biopsy forceps also failed. Attempts to push the stent cephalad, caudad, and back into the biliary tree also failed. After approximately 1 hour of fruitless endoscopic manipulations with repositioning of the patient, a .035-inch Teflon biliary wire was passed through the endoscopic channel (diameter, 4.8 mm) and advanced under endoscopic guidance past the stent. A polypectomy snare was then passed through the same channel and advanced past the stent on the side of the stent opposite to that of the wire. The wire was then ensnared, in effect creating a closed loop around the stent from two separate components. Both wire and closed snare were then simultaneously pulled back into the endoscope until the stent was tightly held against the endoscope. The endoscope and GASTROINTESTINAL ENDOSCOPY
trailing stent were then successfully removed. The patient underwent placement of another 11.5F stent resulting in excellent palliative decompression. Distally migrated stents impacted in the duodenal wall are fortunately a rare event. The above technique allowed for stent retrieval when all other endoscopic techniques had failed. Although both the wire and the snare were passed through the same channel, the duodenoscope's elevator allowed for selective movement of the snare and ultimately the success of the procedure. It is possible that the same technique may have been used with a forward-viewing doublechannel therapeutic endoscope, but none was available. Admittedly a difficult technique, retrieval of the impacted stent with snare and guide wire prevented this rare complication from being much more devastating to this patient and should be considered when standard endoscopic techniques of stent retrieval fail. David S. Weinman, MD Sharp Rees-Stealy Medical Clinic San Diego, California
Balloon removal of an impacted esophageal meat bolus To the Editor: Meat impactions frequently occur in the elderly population. Numerous extracting devices have been used in this situation, including jumbo biopsy forceps, polypectomy snares, and basket retrievers, as well as specialized grasping instruments such as alligator, rat-tooth, and tenaculum forceps.I None of these work particularly well, especially when the meat bolus is partially digested or impacted in the subcricopharyngeal area. This letter describes just such a situation and a new technique that we have found useful for removing impacted meat boluses. A 79-year-old woman presented to the emergency department with acute onset of dysphagia after eating a steak dinner. She stated that this dysphagia had occurred on several occasions over the last 20 years, in one case requiring a difficult extraction with a rigid endoscope. She did not have weight loss, odynophagia, or abdominal pain. She was in no acute distress and had only mild hypersalivation. Her physical examination was unremarkable, as was her laboratory data. A barium swallow revealed a large, partially obstructing meat bolus just below the cricopharyngeal area. The patient was initially treated with intravenous glucagon with no improvement of her symptoms. Endoscopy was then performed, revealing a large piece of meat impacted below the cricopharyngeal area. The meat could not be advanced with forward pressure from the endoscope and because of its immediate subcricopharyngeallocation could neither be easily grasped nor maneuvered. A 15 mm diameter, 3 cm length through-the-scope balloon catheter (Microvasive, Watertown, Mass.) was cautiously advanced beyond the impaction under direct endoscopic guidance. The balloon was maximally inflated with saline and then withdrawn until resistance was encountered. At this point, the VOLUME 40, NO.3, 1994
patient was placed in steep Trendelenburg position and the scope and balloon withdrawn simultaneously. This motion successfully dislodged the meat bolus, displacing it into the oropharynx, where it was readily removed. Re-endoscopy of the patient revealed no obvious rings or obstructing lesions. The entire procedure was well tolerated. The above technique of foreign body removal has been performed by one of the authors on an additional three similar patients. It uses a well-established method for coin removal in infants 2 and has also been used in the past for gastric bubble removal. 3 The technique appears most useful for patients with impaction occurring in the subcricopharyngeal area. It is in this area where endoscopic visualization and manipulation is most difficult and the patient is at highest risk for aspiration. Many patients poorly tolerate repeated passage of the endoscope necessary for piecemeal removal. An average of 10 trips were required for complete removal in one study.4 Because of the high level of impaction, it is difficult or impossible to fully advance an overtube when working in this area. The obvious concern with this technique is aspiration of the foreign body, but in our experience this has not been a problem because of the size of the bolus, the patient being placed in steep Trendelenburg position, and rapid digital removal of the disimpacted meat bolus. We think that this technique represents a significant advance in the management of high esophageal meat impactions and should be considered for use in these situations. Jeffrey H. Goldman, MD Robert I. Goldberg, MD University of Miami, School of Medicine Division of Gastroenterology Mt. Sinai Medical Center Miami, Florida
REFERENCES 1. Goldberg RI, Manten RD. Foreign bodies and bezoars of the
upper gastrointestinal tract. In: Barkin JS, O'Phelan CA, eds. Advanced therapeutic endoscopy. New York: Raven Press, 1990:27 -37. 2. Dunlap LB. Removal of an esophageal foreign body using a Foley catheter. Ann Emerg Med 1981;10:101-3. 3. Blinder M, Goldberg RI, Barkin JS, Phillips RS. A new method for gastric bubble removal. Gastrointest Endosc 1987;33:243-4. 4. Rogers BRG, Kot C, Meiri S, Epstein M. An overtube for the flexible fiberoptic esophagogastroduodenoscope. Gastrointest Endosc 1982;28:256-7.
Improved gastric lavage via direct endoscopic visualization To the Editor: Current endoscopic options for the treatment of active UGI hemorrhage are effective for reducing rebleeding rates. 1 However, interventions for UGI hemorrhage rest on the precise identification of the source of bleeding. The endoscopist often encounters blood or clot that obscures the underlying mucosa from view. Lavage through large-bore tubes or suction through therapeutic gastroscopes may remove a portion ofthe adherent clot. We report a case in which both 391
REFERENCES 1. Osnes M, Rosseland AR, Aabakken L. Endoscopic retrograde
cholangiography and endoscopic papillotomy in patients with a previous Billroth II resection. Gut 1986;27:1193-8. 2. Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut 1984;25:971-4. 3. Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP): a study of 10,000 cases. Gastroenterology 1976;70:314-20.
390
4. Thon RJ, Loffier A, Buess G, Gheorghiu T. Is ERCP a reasonable diagnostic method for excluding pancreatic and hepatobiliary disease in patients with a Billroth II resection? Endoscopy 1983;15:93-5. 5. Safrany L, Neuhaus B, Porto-Carrero G, Krause S. Endoscopic sphincterotomy in patients with Billroth II gastrectomy. Endoscopy 1980;12:16-22. 6. Siegel JR, Yatto RP. ERCP and endoscopic papillotomy in patients with a Billroth II gastrectomy: report of a method. Gastrointest Endosc 1983;29:116-8. 7. Staritz M, Baas U, Ewe K, Meyer-zum-Buschenfelde KH. ERCP using a special catheter with external steering: a reliable aid in typical ERCP problems. Endoscopy 1985;17:26-8. 8. Onken J, Baillie J, Affronti JP, et al. ERCP in patients following Billroth II gastrectomy: is it tougher and riskier than "ordinary" ERCP? [Abstract] Gastrointest Endosc 1992;38:257.
Endoscopic removal of biliary stent impacted in the duodenal wall To the Editor: A 74-year-old woman with metastatic colon cancer presented approximately 7 months ago with obstructive jaundice. A CT scan demonstrated almost complete replacement of the right lobe of the liver with tumor. The left lobe was involved but less so. An ERCP revealed a complex highgrade hilar stricture (type 3). The right intrahepatic biliary ductal system could not be entered. The left system could be entered only with the use of guide wires, and the resultant cholangiogram revealed a high-grade obstruction at the hilum, a second partial obstruction higher up in the left intrahepatic ductal system, and gross dilation above that stricture. A 12-cm-Iong 11.5F Wilson-Cook Cotton-Leung biliary stent (Wilson-Cook, Winston-Salem, N.C.) was then placed, with excellent palliative results. The patient has, however, required stent replacement every 2 to 3 months because of stent occlusion from both sludge and continued tumor growth. Recently, the patient presented with recurrent jaundice. An ERCP with the Olympus T JF -100 therapeutic video duodenoscope (Olympus America Inc., Lake Success, N.Y.) demonstrated a distally migrated stent that was buried in the duodenal wall opposite the ampulla. Multiple attempts were made to retrieve the stent with a polypectomy snare. Attempts to manipulate the snare between the mucosa and the stent tip and attempts to remove the stent by ensnaring the external side flap were unsuccessful. Attempts to retrieve the snare by a variety of biopsy forceps including pelican, rat tooth, and large biopsy forceps also failed. Attempts to push the stent cephalad, caudad, and back into the biliary tree also failed. After approximately 1 hour of fruitless endoscopic manipulations with repositioning of the patient, a .035-inch Teflon biliary wire was passed through the endoscopic channel (diameter, 4.8 mm) and advanced under endoscopic guidance past the stent. A polypectomy snare was then passed through the same channel and advanced past the stent on the side of the stent opposite to that of the wire. The wire was then ensnared, in effect creating a closed loop around the stent from two separate components. Both wire and closed snare were then simultaneously pulled back into the endoscope until the stent was tightly held against the endoscope. The endoscope and GASTROINTESTINAL ENDOSCOPY
trailing stent were then successfully removed. The patient underwent placement of another 11.5F stent resulting in excellent palliative decompression. Distally migrated stents impacted in the duodenal wall are fortunately a rare event. The above technique allowed for stent retrieval when all other endoscopic techniques had failed. Although both the wire and the snare were passed through the same channel, the duodenoscope's elevator allowed for selective movement of the snare and ultimately the success of the procedure. It is possible that the same technique may have been used with a forward-viewing doublechannel therapeutic endoscope, but none was available. Admittedly a difficult technique, retrieval of the impacted stent with snare and guide wire prevented this rare complication from being much more devastating to this patient and should be considered when standard endoscopic techniques of stent retrieval fail. David S. Weinman, MD Sharp Rees-Stealy Medical Clinic San Diego, California
Balloon removal of an impacted esophageal meat bolus To the Editor: Meat impactions frequently occur in the elderly population. Numerous extracting devices have been used in this situation, including jumbo biopsy forceps, polypectomy snares, and basket retrievers, as well as specialized grasping instruments such as alligator, rat-tooth, and tenaculum forceps.I None of these work particularly well, especially when the meat bolus is partially digested or impacted in the subcricopharyngeal area. This letter describes just such a situation and a new technique that we have found useful for removing impacted meat boluses. A 79-year-old woman presented to the emergency department with acute onset of dysphagia after eating a steak dinner. She stated that this dysphagia had occurred on several occasions over the last 20 years, in one case requiring a difficult extraction with a rigid endoscope. She did not have weight loss, odynophagia, or abdominal pain. She was in no acute distress and had only mild hypersalivation. Her physical examination was unremarkable, as was her laboratory data. A barium swallow revealed a large, partially obstructing meat bolus just below the cricopharyngeal area. The patient was initially treated with intravenous glucagon with no improvement of her symptoms. Endoscopy was then performed, revealing a large piece of meat impacted below the cricopharyngeal area. The meat could not be advanced with forward pressure from the endoscope and because of its immediate subcricopharyngeallocation could neither be easily grasped nor maneuvered. A 15 mm diameter, 3 cm length through-the-scope balloon catheter (Microvasive, Watertown, Mass.) was cautiously advanced beyond the impaction under direct endoscopic guidance. The balloon was maximally inflated with saline and then withdrawn until resistance was encountered. At this point, the VOLUME 40, NO.3, 1994
patient was placed in steep Trendelenburg position and the scope and balloon withdrawn simultaneously. This motion successfully dislodged the meat bolus, displacing it into the oropharynx, where it was readily removed. Re-endoscopy of the patient revealed no obvious rings or obstructing lesions. The entire procedure was well tolerated. The above technique of foreign body removal has been performed by one of the authors on an additional three similar patients. It uses a well-established method for coin removal in infants 2 and has also been used in the past for gastric bubble removal. 3 The technique appears most useful for patients with impaction occurring in the subcricopharyngeal area. It is in this area where endoscopic visualization and manipulation is most difficult and the patient is at highest risk for aspiration. Many patients poorly tolerate repeated passage of the endoscope necessary for piecemeal removal. An average of 10 trips were required for complete removal in one study.4 Because of the high level of impaction, it is difficult or impossible to fully advance an overtube when working in this area. The obvious concern with this technique is aspiration of the foreign body, but in our experience this has not been a problem because of the size of the bolus, the patient being placed in steep Trendelenburg position, and rapid digital removal of the disimpacted meat bolus. We think that this technique represents a significant advance in the management of high esophageal meat impactions and should be considered for use in these situations. Jeffrey H. Goldman, MD Robert I. Goldberg, MD University of Miami, School of Medicine Division of Gastroenterology Mt. Sinai Medical Center Miami, Florida
REFERENCES 1. Goldberg RI, Manten RD. Foreign bodies and bezoars of the
upper gastrointestinal tract. In: Barkin JS, O'Phelan CA, eds. Advanced therapeutic endoscopy. New York: Raven Press, 1990:27 -37. 2. Dunlap LB. Removal of an esophageal foreign body using a Foley catheter. Ann Emerg Med 1981;10:101-3. 3. Blinder M, Goldberg RI, Barkin JS, Phillips RS. A new method for gastric bubble removal. Gastrointest Endosc 1987;33:243-4. 4. Rogers BRG, Kot C, Meiri S, Epstein M. An overtube for the flexible fiberoptic esophagogastroduodenoscope. Gastrointest Endosc 1982;28:256-7.
Improved gastric lavage via direct endoscopic visualization To the Editor: Current endoscopic options for the treatment of active UGI hemorrhage are effective for reducing rebleeding rates. 1 However, interventions for UGI hemorrhage rest on the precise identification of the source of bleeding. The endoscopist often encounters blood or clot that obscures the underlying mucosa from view. Lavage through large-bore tubes or suction through therapeutic gastroscopes may remove a portion ofthe adherent clot. We report a case in which both 391