- Email: [email protected]
Novel management of complex hilar biliary strictures with the Spyglass Direct Visualization System (with video)
Brief Reports
0.035-Glidewire was then able to pass into the donor duct, but a taper-tip catheter was not able to follow, because of the right angle at the anastomosis, and slipped by the occluding balloon. The 8.5-mm balloon catheter was exchanged for an 11.5-mm balloon, and the leak was again occluded. This facilitated passage of the guidewire and the catheter deep into the donor duct, which was confirmed with a cholangiogram (Fig. 3). A 10F, 10-cm-long double-pigtail plastic stent was then placed over the guidewire, with its proximal tip in the donor duct (Fig. 4).
DISCUSSION This report describes a new technique of using occlusion of a large biliary anastomotic leak with a balloon catheter to assist in wire passage and device placement into the desired duct. We believe that this technique may be of value in other
instances when the wire and catheters repeatedly pass into a undesired location.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA. Reprint requests: Michael L. Kochman, MD, GI division, 3 Ravdin, HUP, 3400 Spruce St, Philadelphia, PA 19104. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.06.017
Novel management of complex hilar biliary strictures with the Spyglass Direct Visualization System (with video) Yasser M. Bhat, MD, Michael L. Kochman, MD, FASGE Philadelphia, Pennsylvania, USA
CASE REPORT A 60-year-old man presented to an outside hospital with painless jaundice of 5 days’ duration and 5-pound weight loss. His physical examination was unremarkable except for icterus. The abnormal laboratory values were as follows: total bilirubin 9.0 mg/dL (normal 0.3-1.9 mg/dL), alanine aminotransferase 367 IU/L (5-40 IU/L), aspartate aminotransferase 203 IU/L (10-40 IU/L), alkaline phosphatase 812 IU/L (20-120 IU/L) and Ca 19-9 of 29,104 U/mL (!37 U/mL). A contrast enhanced CTand MRCP performed at the outside hospital showed dilated bilateral intrahepatic ducts (1 cm) with a transition point at the confluence of the right hepatic duct (RIHD) and left hepatic duct (LIHD). At 8 mm, the common bile duct (CBD) was not dilated. He underwent an ERCP that demonstrated high-grade stenosis at the confluence of the RIHD and LIHD with the common hepatic duct (CHD). It was neither possible to inject contrast nor pass a guidewire into the LIHD. A 7F plastic stent was placed into the RIHD after passing a guidewire. Brushings of the stricture were nondiagnostic. The patient continued to be jaundiced and was referred to our hospital for further management and surgical evaluation. The MRCP was reviewed, revealing the presence of a hilar (Bismuth IV) stricture (Fig. 1). At repeat ERCP, the 7F stent was removed and a cholangiogram confirmed the presence
of hilar stricture (Fig. 2). Limited contrast injection was performed to avoid contaminating the intrahepatic bile ducts. Multiple attempts to access the LIHD with 0.035-inch and 0.025-inch hydrophilic guidewires were unsuccessful. Due to the difficulty of obtaining access into the intrahepatic ducts bilaterally, a decision was made to use the Spyglass Direct Visualization System ([SDVS] Microvasive, Boston Scientific, Natick, Mass) to further evaluate the lesion. This per oral cholangioscopy system is designed for use by a single operator. It has 3 components: (1) the reusable fiber optic probe for visualization, (2) the disposable access and delivery catheter, and (3) the intraductal forceps. The access catheter has 2 channelsd a working channel intended for the use of biopsy forceps or a guidewire insertion, and a channel intended for the optical probe. A 0.035-inch guidewire was placed into the CHD, and the access catheter was introduced. Friable, erythematous tissue that bled easily on contact was seen on direct visualization of the confluence of the CHD. Intraductal biopsies were performed. It was then decided to place bilateral plastic endoprostheses to decompress the ducts. The guidewire was selectively directed into the LIHD under direct visualization (Figs. 3 and 4, Video 1, available online at www.giejournal.org). By using fluoroscopy, the placement of the wire in the LIHD was confirmed; the
1182 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 6 : 2009
www.giejournal.org
Brief Reports
Figure 3. Spyglass view of the confluence with the guidewire in the LIHD.
Figure 1. MRCP demonstrating a hilar (Bismuth IV) stricture. The arrowheads point to the CBD, LIHD, and RIHD.
Figure 4. Guidewire placement into the LIHD.
were placed across the strictures. The patient had complete resolution of jaundice and is completing his evaluation. Figure 2. Demonstration of complete obstruction of the CHD confluence.
DISCUSSION
fiber optic probe was then removed from the access catheter. A second 0.035-inch guidewire was introduced through the fiber optic probe port and easily placed into the RIHD under fluoroscopy (Fig. 5). The access catheter was then withdrawn from the working channel of the duodenoscope, leaving the 2 guidewires in place. Subsequently, two 10F 12-cm plastic endoprosthetics
In patients with jaundice due to biliary obstruction, endoscopic drainage of the bile ducts is preferable to percutaneous drainage. However, this approach can be technically difficult for hilar strictures. SDVS is a relatively new technique that allows successful cholangioscopy and intraductal biopsy.1 We have described a novel technique that we believe is useful for selective endoprosthetic
www.giejournal.org
Volume 69, No. 6 : 2009 GASTROINTESTINAL ENDOSCOPY 1183
Brief Reports
noncontrast-guided access to the intrahepatic ducts and may decrease the risk of post-ERCP cholangitis. While recognizing that most hilar strictures can be traversed with guidewire manipulation alone, the technique described here may be useful in a subset of difficult patients. This approach should be balanced against the increase in procedural costs associated with it. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Abbreviations: CBD, common bile duct; CHD, common hepatic duct; LIHD, left intrahepatic duct; RIHD, right intrahepatic duct; SDVS, Spyglass Direct Visualization System.
REFERENCES
Figure 5. Bilateral intrahepatic guidewire access with the Spyscope in the CHD.
placement in difficult or failed ERCP for complex hilar biliary strictures. The use of a direct visualization system in this setting provides the following theoretical advantages: (1) an increase in the success rate of placement of bilateral hilar endoprosthetics, and (2) a decrease in the potential infectious complications after ERCP, which occur in 5% to 38% of patients due to inadequate drainage of ducts opacified with contrast.2 Direct visualization allows
1. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65:832-41. 2. Larghi A, Tringali A, Lecca PG, et al. Management of hilar biliary strictures. Am J Gastroenterol 2008;103:458-73.
Gastroenterology Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. Reprint requests: Michael L. Kochman, MD, FASGE, GI Division, 3 Ravdin, HUP, 3400 Spruce Street, Philadelphia, PA 19104. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.07.023
A case of duodenal Entamoeba histolytica Linda A. Feagins, MD, Vincent Chan, MD, Stuart J. Spechler, MD Dallas, Texas, USA
Well known clinical manifestations of infection with Entamoeba histolytica include dysentery and liver abscesses, which uncommonly can extend into the chest and cause pleuro-pulmonary and cardiac infections. E histolytica also has been reported to cause central nervous system (CNS) disease, with brain abscesses from hematogenous spread.1 Infrequently, infected patients develop amebomas, which are localized masses of infected granulation tissue in the intestine whose appearance can mimic colon cancers.2 Amebomas can extend to involve the perianal skin, and there is even a report of a rectovaginal fistulae developing from an ameboma.3 We now report a case of an ameboma involving the duodenum and causing upper-GI bleeding.
A 31-year-old man with HIV infection and AIDS (CD4 count of 4 cells/mL [normal 416-1751 cells/mL], no prior AIDS-defining illnesses) was admitted to Parkland Memorial Hospital complaining of pain in the epigastrium and left upper quadrant, nausea, vomiting, and weight loss over the previous 2 weeks. He had an episode of hematemesis on the day before admission. He denied taking nonsteroidal
1184 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 6 : 2009
www.giejournal.org
To our knowledge, this is the first description of such a lesion.
CASE REPORT
0.035-Glidewire was then able to pass into the donor duct, but a taper-tip catheter was not able to follow, because of the right angle at the anastomosis, and slipped by the occluding balloon. The 8.5-mm balloon catheter was exchanged for an 11.5-mm balloon, and the leak was again occluded. This facilitated passage of the guidewire and the catheter deep into the donor duct, which was confirmed with a cholangiogram (Fig. 3). A 10F, 10-cm-long double-pigtail plastic stent was then placed over the guidewire, with its proximal tip in the donor duct (Fig. 4).
DISCUSSION This report describes a new technique of using occlusion of a large biliary anastomotic leak with a balloon catheter to assist in wire passage and device placement into the desired duct. We believe that this technique may be of value in other
instances when the wire and catheters repeatedly pass into a undesired location.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA. Reprint requests: Michael L. Kochman, MD, GI division, 3 Ravdin, HUP, 3400 Spruce St, Philadelphia, PA 19104. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.06.017
Novel management of complex hilar biliary strictures with the Spyglass Direct Visualization System (with video) Yasser M. Bhat, MD, Michael L. Kochman, MD, FASGE Philadelphia, Pennsylvania, USA
CASE REPORT A 60-year-old man presented to an outside hospital with painless jaundice of 5 days’ duration and 5-pound weight loss. His physical examination was unremarkable except for icterus. The abnormal laboratory values were as follows: total bilirubin 9.0 mg/dL (normal 0.3-1.9 mg/dL), alanine aminotransferase 367 IU/L (5-40 IU/L), aspartate aminotransferase 203 IU/L (10-40 IU/L), alkaline phosphatase 812 IU/L (20-120 IU/L) and Ca 19-9 of 29,104 U/mL (!37 U/mL). A contrast enhanced CTand MRCP performed at the outside hospital showed dilated bilateral intrahepatic ducts (1 cm) with a transition point at the confluence of the right hepatic duct (RIHD) and left hepatic duct (LIHD). At 8 mm, the common bile duct (CBD) was not dilated. He underwent an ERCP that demonstrated high-grade stenosis at the confluence of the RIHD and LIHD with the common hepatic duct (CHD). It was neither possible to inject contrast nor pass a guidewire into the LIHD. A 7F plastic stent was placed into the RIHD after passing a guidewire. Brushings of the stricture were nondiagnostic. The patient continued to be jaundiced and was referred to our hospital for further management and surgical evaluation. The MRCP was reviewed, revealing the presence of a hilar (Bismuth IV) stricture (Fig. 1). At repeat ERCP, the 7F stent was removed and a cholangiogram confirmed the presence
of hilar stricture (Fig. 2). Limited contrast injection was performed to avoid contaminating the intrahepatic bile ducts. Multiple attempts to access the LIHD with 0.035-inch and 0.025-inch hydrophilic guidewires were unsuccessful. Due to the difficulty of obtaining access into the intrahepatic ducts bilaterally, a decision was made to use the Spyglass Direct Visualization System ([SDVS] Microvasive, Boston Scientific, Natick, Mass) to further evaluate the lesion. This per oral cholangioscopy system is designed for use by a single operator. It has 3 components: (1) the reusable fiber optic probe for visualization, (2) the disposable access and delivery catheter, and (3) the intraductal forceps. The access catheter has 2 channelsd a working channel intended for the use of biopsy forceps or a guidewire insertion, and a channel intended for the optical probe. A 0.035-inch guidewire was placed into the CHD, and the access catheter was introduced. Friable, erythematous tissue that bled easily on contact was seen on direct visualization of the confluence of the CHD. Intraductal biopsies were performed. It was then decided to place bilateral plastic endoprostheses to decompress the ducts. The guidewire was selectively directed into the LIHD under direct visualization (Figs. 3 and 4, Video 1, available online at www.giejournal.org). By using fluoroscopy, the placement of the wire in the LIHD was confirmed; the
1182 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 6 : 2009
www.giejournal.org
Brief Reports
Figure 3. Spyglass view of the confluence with the guidewire in the LIHD.
Figure 1. MRCP demonstrating a hilar (Bismuth IV) stricture. The arrowheads point to the CBD, LIHD, and RIHD.
Figure 4. Guidewire placement into the LIHD.
were placed across the strictures. The patient had complete resolution of jaundice and is completing his evaluation. Figure 2. Demonstration of complete obstruction of the CHD confluence.
DISCUSSION
fiber optic probe was then removed from the access catheter. A second 0.035-inch guidewire was introduced through the fiber optic probe port and easily placed into the RIHD under fluoroscopy (Fig. 5). The access catheter was then withdrawn from the working channel of the duodenoscope, leaving the 2 guidewires in place. Subsequently, two 10F 12-cm plastic endoprosthetics
In patients with jaundice due to biliary obstruction, endoscopic drainage of the bile ducts is preferable to percutaneous drainage. However, this approach can be technically difficult for hilar strictures. SDVS is a relatively new technique that allows successful cholangioscopy and intraductal biopsy.1 We have described a novel technique that we believe is useful for selective endoprosthetic
www.giejournal.org
Volume 69, No. 6 : 2009 GASTROINTESTINAL ENDOSCOPY 1183
Brief Reports
noncontrast-guided access to the intrahepatic ducts and may decrease the risk of post-ERCP cholangitis. While recognizing that most hilar strictures can be traversed with guidewire manipulation alone, the technique described here may be useful in a subset of difficult patients. This approach should be balanced against the increase in procedural costs associated with it. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Abbreviations: CBD, common bile duct; CHD, common hepatic duct; LIHD, left intrahepatic duct; RIHD, right intrahepatic duct; SDVS, Spyglass Direct Visualization System.
REFERENCES
Figure 5. Bilateral intrahepatic guidewire access with the Spyscope in the CHD.
placement in difficult or failed ERCP for complex hilar biliary strictures. The use of a direct visualization system in this setting provides the following theoretical advantages: (1) an increase in the success rate of placement of bilateral hilar endoprosthetics, and (2) a decrease in the potential infectious complications after ERCP, which occur in 5% to 38% of patients due to inadequate drainage of ducts opacified with contrast.2 Direct visualization allows
1. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65:832-41. 2. Larghi A, Tringali A, Lecca PG, et al. Management of hilar biliary strictures. Am J Gastroenterol 2008;103:458-73.
Gastroenterology Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. Reprint requests: Michael L. Kochman, MD, FASGE, GI Division, 3 Ravdin, HUP, 3400 Spruce Street, Philadelphia, PA 19104. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.07.023
A case of duodenal Entamoeba histolytica Linda A. Feagins, MD, Vincent Chan, MD, Stuart J. Spechler, MD Dallas, Texas, USA
Well known clinical manifestations of infection with Entamoeba histolytica include dysentery and liver abscesses, which uncommonly can extend into the chest and cause pleuro-pulmonary and cardiac infections. E histolytica also has been reported to cause central nervous system (CNS) disease, with brain abscesses from hematogenous spread.1 Infrequently, infected patients develop amebomas, which are localized masses of infected granulation tissue in the intestine whose appearance can mimic colon cancers.2 Amebomas can extend to involve the perianal skin, and there is even a report of a rectovaginal fistulae developing from an ameboma.3 We now report a case of an ameboma involving the duodenum and causing upper-GI bleeding.
A 31-year-old man with HIV infection and AIDS (CD4 count of 4 cells/mL [normal 416-1751 cells/mL], no prior AIDS-defining illnesses) was admitted to Parkland Memorial Hospital complaining of pain in the epigastrium and left upper quadrant, nausea, vomiting, and weight loss over the previous 2 weeks. He had an episode of hematemesis on the day before admission. He denied taking nonsteroidal
1184 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 6 : 2009
www.giejournal.org
To our knowledge, this is the first description of such a lesion.
CASE REPORT