EUS-guided transduodenal biliary drainage

EUS-guided transduodenal biliary drainage

AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points EUS-guided transduodenal biliary drainage A 71-year-old woman presented...

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AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points

EUS-guided transduodenal biliary drainage

A 71-year-old woman presented with painless obstructive jaundice (total bilirubin 161 umol/L, and total ALP 459 IU/L). Transabdominal ultrasound examination showed a 2-cm mass at the pancreatic head with multiple tiny cystic components that produced a “doubleduct” sign. ERCP was attempted twice but was unsuccessful. EUS-guided transduodenal drainage was eventually performed using a curvilinear echoendoscope (GF-UCT2000-OL5 [Olympus Medical Systems Co. Ltd., Tokyo, Japan]) to puncture the common bile duct with a 19 G-needle (Echotip ECHO-19 [Cook Medical Inc., Bloomington, Indiana, USA] ) under direct EUS guidance. A 0.035-inch guidewire then was passed through the needle into the common bile duct and advanced up into the intrahepatic duct. The needle was exchanged for a needle-knife (KD-441Q [Olympus Medical Systems Co. Ltd., Tokyo, Japan]), and a choledochoduodenal fistula was created by electrocautery along the guidewire. Finally, a 7-cm double-pigtail stent (7F) was placed to maintain patency of the fistula (A). Serum bilirubin levels and liver biochemical tests normalized, and a Whipple operation was scheduled to be done several weeks later. Intraoperatively, a 3-cm welldifferentiated ductal adenocarcinoma was found in the uncinate process, with the double-pigtail stent still insitu (B). Periductal adhesion and edema were present, and histology of serosal surfaces sampled around the choledochoduodenostomy showed reactive fibroblastic 186 GASTROINTESTINAL ENDOSCOPY

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tissue with a mild mixed inflammatory infiltrate composed mainly of small lymphocytes, plasma cells, and occasional neutrophils. No microabscess formation or dense fibrosis was identified. This inflammatory reaction was believed to be a desmoplastic stromal reaction from the pancreatic head cancer rather than the choledochoduodenostomy (C). www.giejournal.org

At the Focal Point

ACKNOWLEDGMENT We are indebted to the Surgical Hepatobiliary Team of Prince of Wales Hospital for their generous assistance in the management of the patient. DISCLOSURE All authors disclosed no financial relationships relevant to this publication.

Larry H. Lai, MD, MRCP(UK), FHKAM(Medicine), Francis K.L. Chan, MD, FRCP, Joseph J.Y. Sung, MD, PhD, Institute of Digestive Disease, The Chinese University of Hong Kong Anthony W.H. Chan, MBChB, Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong K. F. Lee, FRCS, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong doi:10.1016/j.gie.2010.01.052

Commentary ERCP with transpapillary biliary drainage is the procedure of choice for biliary decompression in patients with unresectable pancreatic cancer. When ERCP is unsuccessful because of gastroduodenal stenosis or previous GI surgery, the usual alternative is percutaneous transhepatic cholangiography with biliary drainage. There are reports of other options scattered in the literature, including transesophageal, transgastric, transjejunal, and, as illustrated in this case, a transduodenal approach. Which route to take is dictated by the anatomy and individual circumstances of each patient. We can listen to the advice of the great American basketball player and coach, Pat Riley, who said to his players, “Look for your choices, pick the best one, and go with it.” With regard to the desmoplastic reaction, the term desmoplasia originates from the Greek words desmos (meaning fetter or band) and plasia (meaning to form), and is used clinically to refer to the fibrous reaction accompanying inflammatory processes and is associated with a variety of neoplasms. There are complex molecular interactions that occur between neoplastic and stromal cells within tumor microenvironments that play an increasingly studied but still poorly understood role in cancer pathogenesis. Just like the adipocytes in the “creeping fat” of inflammatory bowel disease that have been shown to be metabolically active and to modify the inflammation associated with Crohn’s disease, carcinoma-associated fibroblasts produce tumor enhancing and inflammatory factors that have been strongly implicated in cancer development. The relationships among inflammation, fibroblast metabolism, tumor growth, angiogenesis, matrix remodeling, and the signaling mechanisms that encourage or retard these variables are matters of intense importance and study. Lawrence J. Brandt, MD Associate Editor for Focal Points

Angioleiomyoma of the small intestine detected by double-balloon enteroscopy A 45-year-old woman had been admitted to a local hospital with intermittent melena that necessitated repeated blood transfusions. Examination by EGD and colonoscopy failed to detect the source of bleeding, and she was referred to our department for further evaluation. Physical examination was unremarkable, apart from pallor. Laboratory investigations showed a hemoglobin level of 8.4 g/dL. The patient underwent wireless capsule endoscopy (CE) that revealed oozing of blood in the ileum; however, no significant lesion was observed. An emergent double-balloon enteroscopy (DBE) was performed via the antegrade approach on the same day as the CE. In the mid-ileum, DBE revealed a smooth, round tumor with a nipple-like appearance and a vessel-like reddish nodule capping its top (A). CT scan revealed a small high-density, enhancing lesion in the small intestine (B). The patient underwent a laparoscopic ileectomy. The ileal tumor was 5 mm in diameter. Histology showed many vascular channels and fascicular proliferation of spindle cells, which were positive for ␣-smooth muscle www.giejournal.org

actin and negative for CD34 and c-kit (C). The final diagnosis was angioleiomyoma. After surgical resection, there was no further GI bleeding or progression of the anemia. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Masami Nakatani, MD, Yasuhiro Fujiwara, MD, PhD, Natsuhiko Kameda, MD, PhD, Hirotoshi Okazaki, MD, Toshio Watanabe, MD, PhD, Kazunari Tominaga, MD, PhD, Tetsuo Arakawa, MD, PhD, Department of Gastroenterology, Eiji Noda, MD, PhD, Toru Inoue, MD, PhD, Kiyoshi Maeda, MD, PhD, Kosei Hirakawa, MD, PhD, Department of Surgical Oncology, Kenichi Wakasa, MD, PhD, Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Osaka, Japan. doi:10.1016/j.gie.2009.12.037

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