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Intestinal perforation after ERCP in Billroth II partial gastrectomy
IDEWIRE AND ACCESSORY LUMEN
Intestinal perforation after ERCP in Billroth II partial gastrectomy To the Editor:
LUMEN
Figure 2. Cross-sectional diagram of the d.ouble-Iumen ERCP catheter.
Step 1. Standard cannulating position is achieved. Step 2. The cannula is inserted into the papilla gently. When the endoscopist feels that the intended position for injection has been obtained, injection via the contrast lumen occurs. The catheter is easily seen on fluoroscopy independent of the wire guide. Step 3. If the intended duct is filled, the wire guide is in place for therapeutic purposes if needed. Step 4. If difficulty is encountered with filling the desired duct, the wire guide that is being housed in the device lumen will allow the endoscopist to modify the standard cannulating technique to a wire-guided technique. Should it be necessary to inject during this technique to confirm the location of the catheter, the catheter allows for this. Step 5. Again, once cannulation has been achieved, the guide wire is in place should therapeutic needs be present. Although there have been great strides made in ERCP, it is clear from the frequent appearance of articles dealing with selective cannulation that there is still significant room for improvement. The dual-lumen ERCP catheter system offers new possibilities. Appropriate use of the catheter should discourage techniques that are traumatic to the ampulla. If gentle maneuvering around the papilla does not allow cannulation, one has the option to utilize the guide wire. A number of features of the DLC may allow for safer cannulation. The contrast lumen does not allow for rapid injection of contrast, thereby discouraging overinjecting the pancreatic duct. With the device lumen being loaded with a guide wire one can turn to a wire-guided cannulation technique with great ease in the hopes of avoiding intramural injection. In addition, one can blend both injection and wire-guided techniques. Once selective cannulation has been achieved with the DLC, the endoscopist will have the choice of removing the catheter and keeping the guide wire in place for therapeutic purposes or removing the guide wire from the device lumen and placing anyone of a family of other miniature devices currently in development. Harold Jacob, MD Cedarhurst, New York
REFERENCES 1. Rossos PG, Kortan P, Haber G. Selective common bile duct
cannulation can be simplified by the use of standard papillotome. Gastrointest Endosc 1993;39:67-9. 2. Sunderland GT, Morran CG, Carter DC. Pancreatic and biliary pressure changes during ERCP. Surg Endosc 1990;4:23. VOLUME 40, NO.3, 1994
It has been stated that in the presence of Billroth II partial gastrectomy, success rates and complication rates are no different from those in the un operated patient. 1 Others do not share this success. 2 Free intestinal perforation after ERCP has occurred in small numbers from the earliest days, usually in association with Billroth II partial gastrectomies or other anatomical abnormalities. 3 We report two cases of free intestinal perforation during diagnostic ERCP in patients with prior Billroth II partial gastrectomy. An 84-year-old woman presented with a short history of painless obstructive jaundice. Examination revealed a thin lady who was obviously jaundiced. A right paramedian scar was observed, but no history was obtained relating to this. Liver function tests showed raised alkaline phosphatase and bilirubin levels. Ultrasound scan demonstrated a dilated common bile duct with no evidence of choledocholithiasis. At ERCP it became clear that a Billroth II partial gastrectomy had been performed. The efferent loop was entered easily and was healthy to the full extent of the examination. The afferent loop was hemorrhagic around the orifice and was difficult to enter. On the second attempt to enter, with the duodenoscope being only 70 cm beyond the teeth and with only moderate pressure, a sudden appearance of the serosal surface of hollow viscera was seen. After maximum air aspiration the endoscope was removed, an intravenous infusion started, and nasogastric tube inserted. At laparotomy later the same day, a 5 cm tear was found in the afferent loop just distal to the anastomotic site. A small mass was located in the pancreas but was not biopsied. An operative bypass procedure was performed. The patient made an uneventful recovery and was discharged from the hospital 15 days later but died after an additional 7 1/2 months because of disseminated carcinoma of the pancreas. A 47-year-old man was admitted to the intensive care unit of this hospital in July 1992 with acute pancreatitis after a transfer from a district intensive care unit. In March 1992, he had undergone cholecystectomy after an episode of acute cholecystitis secondary to gallstones. The operation was complicated by pre-renal failure. He was readmitted in July 1992 after an episode of epigastric pain. A diagnosis of acute pancreatitis was made, with a serum amylase level of 1015
lUlL. Medical history included a perforated duodenal ulcer and a Billroth II partial gastrectomy in 1969. There was a history of myocardial infarction, and in 1987 the patient had a heart transplant for ischemic heart disease. The patient was acutely ill and febrile, and required endotracheal intubation. Ultrasound scan showed a dilated common bile duct with an irregular cystic area in the gallbladder fossa, which was drained percutaneously, and grew gram-negative bacilli. A CT scan of the abdomen was unremarkable. His general condition failed to improve on antibiotics, and therefore an ERCP was performed. At ERCP the Billroth II gastrectomy was noted. Within a short space of time and after a single pass into the efferent loop, there was a perforation close to the anastomosis. The proce389
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.
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
Intestinal perforation after ERCP in Billroth II partial gastrectomy To the Editor:
LUMEN
Figure 2. Cross-sectional diagram of the d.ouble-Iumen ERCP catheter.
Step 1. Standard cannulating position is achieved. Step 2. The cannula is inserted into the papilla gently. When the endoscopist feels that the intended position for injection has been obtained, injection via the contrast lumen occurs. The catheter is easily seen on fluoroscopy independent of the wire guide. Step 3. If the intended duct is filled, the wire guide is in place for therapeutic purposes if needed. Step 4. If difficulty is encountered with filling the desired duct, the wire guide that is being housed in the device lumen will allow the endoscopist to modify the standard cannulating technique to a wire-guided technique. Should it be necessary to inject during this technique to confirm the location of the catheter, the catheter allows for this. Step 5. Again, once cannulation has been achieved, the guide wire is in place should therapeutic needs be present. Although there have been great strides made in ERCP, it is clear from the frequent appearance of articles dealing with selective cannulation that there is still significant room for improvement. The dual-lumen ERCP catheter system offers new possibilities. Appropriate use of the catheter should discourage techniques that are traumatic to the ampulla. If gentle maneuvering around the papilla does not allow cannulation, one has the option to utilize the guide wire. A number of features of the DLC may allow for safer cannulation. The contrast lumen does not allow for rapid injection of contrast, thereby discouraging overinjecting the pancreatic duct. With the device lumen being loaded with a guide wire one can turn to a wire-guided cannulation technique with great ease in the hopes of avoiding intramural injection. In addition, one can blend both injection and wire-guided techniques. Once selective cannulation has been achieved with the DLC, the endoscopist will have the choice of removing the catheter and keeping the guide wire in place for therapeutic purposes or removing the guide wire from the device lumen and placing anyone of a family of other miniature devices currently in development. Harold Jacob, MD Cedarhurst, New York
REFERENCES 1. Rossos PG, Kortan P, Haber G. Selective common bile duct
cannulation can be simplified by the use of standard papillotome. Gastrointest Endosc 1993;39:67-9. 2. Sunderland GT, Morran CG, Carter DC. Pancreatic and biliary pressure changes during ERCP. Surg Endosc 1990;4:23. VOLUME 40, NO.3, 1994
It has been stated that in the presence of Billroth II partial gastrectomy, success rates and complication rates are no different from those in the un operated patient. 1 Others do not share this success. 2 Free intestinal perforation after ERCP has occurred in small numbers from the earliest days, usually in association with Billroth II partial gastrectomies or other anatomical abnormalities. 3 We report two cases of free intestinal perforation during diagnostic ERCP in patients with prior Billroth II partial gastrectomy. An 84-year-old woman presented with a short history of painless obstructive jaundice. Examination revealed a thin lady who was obviously jaundiced. A right paramedian scar was observed, but no history was obtained relating to this. Liver function tests showed raised alkaline phosphatase and bilirubin levels. Ultrasound scan demonstrated a dilated common bile duct with no evidence of choledocholithiasis. At ERCP it became clear that a Billroth II partial gastrectomy had been performed. The efferent loop was entered easily and was healthy to the full extent of the examination. The afferent loop was hemorrhagic around the orifice and was difficult to enter. On the second attempt to enter, with the duodenoscope being only 70 cm beyond the teeth and with only moderate pressure, a sudden appearance of the serosal surface of hollow viscera was seen. After maximum air aspiration the endoscope was removed, an intravenous infusion started, and nasogastric tube inserted. At laparotomy later the same day, a 5 cm tear was found in the afferent loop just distal to the anastomotic site. A small mass was located in the pancreas but was not biopsied. An operative bypass procedure was performed. The patient made an uneventful recovery and was discharged from the hospital 15 days later but died after an additional 7 1/2 months because of disseminated carcinoma of the pancreas. A 47-year-old man was admitted to the intensive care unit of this hospital in July 1992 with acute pancreatitis after a transfer from a district intensive care unit. In March 1992, he had undergone cholecystectomy after an episode of acute cholecystitis secondary to gallstones. The operation was complicated by pre-renal failure. He was readmitted in July 1992 after an episode of epigastric pain. A diagnosis of acute pancreatitis was made, with a serum amylase level of 1015
lUlL. Medical history included a perforated duodenal ulcer and a Billroth II partial gastrectomy in 1969. There was a history of myocardial infarction, and in 1987 the patient had a heart transplant for ischemic heart disease. The patient was acutely ill and febrile, and required endotracheal intubation. Ultrasound scan showed a dilated common bile duct with an irregular cystic area in the gallbladder fossa, which was drained percutaneously, and grew gram-negative bacilli. A CT scan of the abdomen was unremarkable. His general condition failed to improve on antibiotics, and therefore an ERCP was performed. At ERCP the Billroth II gastrectomy was noted. Within a short space of time and after a single pass into the efferent loop, there was a perforation close to the anastomosis. The proce389
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.
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