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Esophageal intubation with the side-viewing endoscope
4. Busuttil RW, Brin BJ. The diagnosis and management of visceral artery aneurysms. Surgery 1980;88:619-24. 5. Countryman D, Norwood S, Register D, Torma M, Andrassi R. Hepatic artery aneurysm. Am Surg 1983;49:51-4.
Esophageal intubation with the sideviewing endoscope To the Editor: Esophageal intubation with the side-viewing endoscope can sometimes be difficult. Standard techniques such as having the patient swallow or guiding the scope with an examining finger do not always succeed. This is especially true in patients with prior oropharyngeal surgery or prior strokes. We have used a technique which is quick, and makes esophageal intubation easier and safer in these difficult cases. A 25- to 3D-em piece of flexible tubing, which will accept a side-viewing endoscope, is required. I have found that the standard barium enema tubing is perfect, and usually readily available in the radiology department. The tube is threaded over a standard forward-viewing endoscope after being well lubricated. The esophagus is then intubated under direct visualization with the forward-viewing endoscope and the endoscope is passed into the distal esophagus. The outside of the tubing is then well lubricated and the tubing gently threaded over the endoscope and into the esophagus as an overtube. It is generally helpful to grasp the tip of the tube with hemostats, to maintain a good hold on the overtube. The endoscope is then slowly withdrawn and the distal tip of the overtube visualized in the proximal esophagus. The forward-viewing endoscope is then removed. The side-viewing endoscope is well lubricated and slowly threaded through the overtube and into the stomach. The overtube is then pulled back over the endoscope and gently cut off with scissors. This allows ERCP to be performed in the usual fashion. I have found this technique to be very effective in difficult esophageal intubations. The whole procedure can be accomplished in 5 min.
A 68-year-old man with obstructive jaundice due to pancreatic cancer was referred to our endoscopic department for endoscopic biliary drainage. Ultrasound and CT studies demonstrated an area of diffuse enlargement in the head of pancreas associated with a change in contour and dilation of common and intra-hepatic bile ducts. The soft tissue planes around the pancreas were disrupted by tumor invasion. The bilirubin level was 22 mg/dl and coagulation parameters were normal. The papilla was normal and cannulation revealed a double duct lesion. A deep cannulation of the biliary duct through the papillary opening for insertion of sphincterotome and endoprosthesis failed. A choledochoduodenal fistula using a diathermic needle knife was performed in the papillary mound,6 and a standard cannula was introduced deeply into the new orifice with no apparent bleeding. When contrast was injected, we saw on the x-ray monitor an image similar to the biliary tree that disappeared in few seconds (Fig. 1). A second injection had a similar result and the contrast flowed quickly in the direction of the liver. With suction, we collected pure blood in the syringe. At that time, we understood that opacification of the portal veins occurred. The patient was well and no clinical symptoms of hemorrhage developed. The procedure was continued and cannulation through the papillary opening was tried again employing a catheter/guidewire assembly. At this second attempt the catheter was able to be advanced through the biliary stricture and cholangiography was successful. Xray revealed marked dilation of the common and intrahepatic bile ducts and a distal stenosis caused by pancreatic carcinoma. A 10 F endoprosthesis was successfully introduced and bile drained out of the stent into the duodenum without blood. The patient's post-ERCP hospital course was uneventful and he was discharged 7 days after the endoscopic procedure. Huibregtse et al. 5 reported a case of filling of the venous vascular system around the papilla following endo-
Steven E. Hearne, MD South Texas Gastroenterology Consultants San Antonio, Texas
Portal vein filling: a rare complication associated with ERCP for endoscopic biliary stent placement To the Editor: Most of complications secondary to ERCP and subsequent operative procedures are well known. 1 Conversely, a number of unusual complications such as hepatic venous gas,2 common hepatic duct perforation,s bleeding from unusual sites, 4 and filling of the venous vascular system around the papilla5 are much less known. They are mainly reported in the Letters to the Editor or Case Report sections that, in our opinion, offer very interesting and instructive reading. Thus, we have decided to report an unusual complication that we have experienced. 524
Figure 1. Full opacification of portal veins at cannulation through a choledochoduodenal fistula. GASTROINTESTINAL ENDOSCOPY
Esophageal intubation with the sideviewing endoscope To the Editor: Esophageal intubation with the side-viewing endoscope can sometimes be difficult. Standard techniques such as having the patient swallow or guiding the scope with an examining finger do not always succeed. This is especially true in patients with prior oropharyngeal surgery or prior strokes. We have used a technique which is quick, and makes esophageal intubation easier and safer in these difficult cases. A 25- to 3D-em piece of flexible tubing, which will accept a side-viewing endoscope, is required. I have found that the standard barium enema tubing is perfect, and usually readily available in the radiology department. The tube is threaded over a standard forward-viewing endoscope after being well lubricated. The esophagus is then intubated under direct visualization with the forward-viewing endoscope and the endoscope is passed into the distal esophagus. The outside of the tubing is then well lubricated and the tubing gently threaded over the endoscope and into the esophagus as an overtube. It is generally helpful to grasp the tip of the tube with hemostats, to maintain a good hold on the overtube. The endoscope is then slowly withdrawn and the distal tip of the overtube visualized in the proximal esophagus. The forward-viewing endoscope is then removed. The side-viewing endoscope is well lubricated and slowly threaded through the overtube and into the stomach. The overtube is then pulled back over the endoscope and gently cut off with scissors. This allows ERCP to be performed in the usual fashion. I have found this technique to be very effective in difficult esophageal intubations. The whole procedure can be accomplished in 5 min.
A 68-year-old man with obstructive jaundice due to pancreatic cancer was referred to our endoscopic department for endoscopic biliary drainage. Ultrasound and CT studies demonstrated an area of diffuse enlargement in the head of pancreas associated with a change in contour and dilation of common and intra-hepatic bile ducts. The soft tissue planes around the pancreas were disrupted by tumor invasion. The bilirubin level was 22 mg/dl and coagulation parameters were normal. The papilla was normal and cannulation revealed a double duct lesion. A deep cannulation of the biliary duct through the papillary opening for insertion of sphincterotome and endoprosthesis failed. A choledochoduodenal fistula using a diathermic needle knife was performed in the papillary mound,6 and a standard cannula was introduced deeply into the new orifice with no apparent bleeding. When contrast was injected, we saw on the x-ray monitor an image similar to the biliary tree that disappeared in few seconds (Fig. 1). A second injection had a similar result and the contrast flowed quickly in the direction of the liver. With suction, we collected pure blood in the syringe. At that time, we understood that opacification of the portal veins occurred. The patient was well and no clinical symptoms of hemorrhage developed. The procedure was continued and cannulation through the papillary opening was tried again employing a catheter/guidewire assembly. At this second attempt the catheter was able to be advanced through the biliary stricture and cholangiography was successful. Xray revealed marked dilation of the common and intrahepatic bile ducts and a distal stenosis caused by pancreatic carcinoma. A 10 F endoprosthesis was successfully introduced and bile drained out of the stent into the duodenum without blood. The patient's post-ERCP hospital course was uneventful and he was discharged 7 days after the endoscopic procedure. Huibregtse et al. 5 reported a case of filling of the venous vascular system around the papilla following endo-
Steven E. Hearne, MD South Texas Gastroenterology Consultants San Antonio, Texas
Portal vein filling: a rare complication associated with ERCP for endoscopic biliary stent placement To the Editor: Most of complications secondary to ERCP and subsequent operative procedures are well known. 1 Conversely, a number of unusual complications such as hepatic venous gas,2 common hepatic duct perforation,s bleeding from unusual sites, 4 and filling of the venous vascular system around the papilla5 are much less known. They are mainly reported in the Letters to the Editor or Case Report sections that, in our opinion, offer very interesting and instructive reading. Thus, we have decided to report an unusual complication that we have experienced. 524
Figure 1. Full opacification of portal veins at cannulation through a choledochoduodenal fistula. GASTROINTESTINAL ENDOSCOPY