- Email: [email protected]
Percutaneous endoscopic biliary stent placement after Whipple resection
or the diameter of plastic stents. They can be safely inserted endoscopically with a high degree of success and provide rapid and effective biliary drainage. 7• 9 Late occlusion by bacterial biofilm or biliary sludge is uncommon. Stent blockage due to tumor ingrowth or overgrowth is, however, a common late complication, occurring in up to 40% of cases, sometimes as early as 1 month after placement. This complication presents a significant management problem, because unlike plastic stents, a blocked metal stent cannot be removed and replaced. The most common method of dealing with this complication has been the insertion of a further stent, plastic or metal, within the blocked lumen. 6 A clearance balloon can be used to remove tumor piecemeal, but perforation of the balloon on exposed edges of the metal struts may occur. 6 Cremer et al. 7 have also employed "diathermic cleansing" in two cases. Using an 8 to 10 F sleeve, a diathermy probe was passed through the stricture several times until recanalization was achieved; tumor ingrowths recurred 1 and 3 months later and were successfully re-treated with this method. Intraluminal irradiation with or without external beam radiotherapy has been used to delay the progression of both pancreatic and bile duct cancer.8.IO-I2 The iridium-192 wire can be safely inserted via a NBT along the biliary tract and 6000 cGy at 5 mm delivered to the tumor over a period of 3 to 5 days. In combination with a standard plastic stent, biliary drainage can be maintained in spite of obstructing the NBT with the wire. l l Following intraluminal radiotherapy, the plastic stent can be removed with long-term preservation of luminal patency, as in this case. This is a major advantage compared with the other methods described for managing the problem which require repeated ERCP for replacing blocked stents or coring out recurrent tumor ingrowth. Treatment with palliative intraluminal iridium-192
irradiation is an option which should be considered in the management of malignant blockage of metal stents in those patients likely to survive long enough to otherwise require frequent endoscopic intervention.
REFERENCES 1. Speer AG, Russell CG, Hatfield ARW, et al. Randomized trial
2. 3. 4.
5.
6.
7.
8. 9.
10. 11. 12.
of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57-62. Sohendra N, Grimm H, Berger B, Nam VC. Malignant jaundice: results of diagnostic and therapeutic endoscopy. World J Surg 1989;13:171-7. Speer AG, Cotton PB, Macrae KD. Endoscopic management of biliary obstruction-Stents of 10 F are preferable to stents of 8 F gauge. Gastrointest Endosc 1988;34:412-7. Fockens P, Cheng J, Coene PPLO, Huibregtse K. Endoscopic treatment of biliary strictures with an expandable metal stent; 6-month follow-up [Abstract), World Congress of Gastroenterology, Sydney, Australia, 1990. Neuhaus H, Hagenmuller F, Classen M. Percutaneous transhepatic and endoscopic transpapillary implantation of selfexpanding biliary stents [Abstract]. World Congress of Gastroenterology, Sydney, Australia, 1990. Williams SJ, Carr-Locke D, Cremer M, et al. Self-expanding metal stents (Wallstent) in the endoscopic palliation of malignant biliary obstruction [Abstract]. World Congress of Gastroenterology, Sydney, Australia, 1990. Cremer M, Deviere J, Sugai B, Baize M. Expandable biliary metal stents for malignancies: endoscopic insertion and diathermic cleansing for tumor ingrowth. Gastrointest Endosc 1990;6:451-7. Levitt MD, Laurence BH, Cameron F, Klemp PFB. Transpapillary iridium-192 in the treatment of malignant bile duct obstruction. Gut 1988;29:149-52. Huibregtse K, Cheng J, Coene PPLO, Fockens P, Tytgat GNJ. Endoscopic placement of expandable metal stents for biliary strictures-a preliminary report on experience with 33 patients. Endoscopy 1989;21:280-2. Meyers WC, Jones RS. Internal radiation for bile duct cancer. World J Surg 1988;12:99-104. Laurence BH. Iridium-192 irradiation of biliary tract malignancy. In: Jacobson 1M, ed. ERCP: diagnostic and therapeutic applications. New York: Elsevier, 1989:239-50. Moertel CG, Frytak S, Hahn RG, et al. Therapy of locally unresectable pancreatic carcinoma: a randomised comparison of high dose (6,000 rads) radiation alone, moderate dose radiation (4,000 rads + 5 fluorouracil) and high dose radiation + 5 fluorouracil. Cancer 1981;48:1705-10.
Case Re po rts Percutaneous endoscopic biliary stent placement after Whipple resection Stephen K. Buto, MD Tat-Kin Tsang, MD Arthur R. Crampton, MD
Pancreatic carcinoma generally carries a very poor prognosis. Surgical cure is usually attempted in fit From the Gastrointestinal Laboratory, Evanston Hospital, Evanston, IL. Reprint requests: Tat-Kin Tsang, MD, c/o Gastrointestinal Laboratory, Evanston Hospital, 2650 Ridge Avenue, Evanston, IL 60201.
498
patients who have evidence of localized resectable pancreatic carcinoma, yet only 10% of patients have potentially curable disease at the time of clinical presentation. I In spite of extensive operative exploration, including sampling of regional lymph nodes, microscopic evidence of malignant spread can go undetected. Although some patients who undergo a Whipple resection (partial pancreatectomy, en bloc duodenectomy and cholecystectomy, coupled with choledocho-, pancreatico-, and gastroenterostomy) experience obstructive jaundice due to recurrent maligGASTROINTESTINAL ENDOSCOPY
nancy, the tumor debulking provides a longer diseasefree interval, especially when coupled with adjuvant radiation and chemotherapy.2 In 5 to 10% of postWhipple patients, recurrent obstructive jaundice as a late post-operative complication is caused by stricture at the bilio-enteric anastomosis, requiring surgical reconstruction. 3 Whether benign or malignant, there are few non-surgical options for restoring biliary drainage in patients with recurrent obstructive jaundice after Whipple resection, aside from percutaneous external drainage. Herein, we describe the internal biliary drainage and dilation of a stricture at a bilioenteric anastomosis after a Whipple resection for pancreatic carcinoma.
was used to conduct contrast material to visualize the position and patency of the stent. Later, at laparotomy, a needle aspirate of the pancreatic head mass was interpreted as mucinous cystadenocarcinoma, and a Whipple resection was performed (Fig. 1A). However, final pathologic diagnosis of the resected specimen revealed a well-differentiated adenocarcinoma in the pancreatic head and in only 1 of 10 peripancreatic lymph nodes. The patient's post-operative course was complicated by the development of multiple hepatic abscesses. Enterococcus iaecalis and Staphylococcus epidermidis were isolated from blood cultures and from the abscesses. Abdominal CT revealed progressive intrahepatic bile duct dilation. In October
CASE REPORT
A 58-year-old man presented in April 1990 with painless jaundice. CT demonstrated intra-hepatic and extra-hepatic bile duct distention and a prominent pancreatic head but no distinct mass. ERCP revealed a "double duct" sign, but a guidewire could not be passed through the biliary obstruction in a retrograde manner, therefore a 7-cm 11.5 F CottonLeung biliary stent was placed using the combined percutaneous endoscopic biliary stenting (PEBS) method previously described. 4- 1o Approaching from the mid-axillary line below the costophrenic angle, a Chiba-type 22-gauge needle was placed into the dilated intra-hepatic bile ducts. Using a coaxial entry system (Acustick; Meditech, Watertown, Mass.) a 6 F catheter was passed through the tumor into the duodenum. A measuring guidewire was placed and centimeter divisions counted between anatomical points above the stenosis and below the ampulla. An 11.5 F stent was selected 1.0 em shorter than the length of the measured stenosis. From a preassembled commercially available kit (CT-PEPS combined procedure kit; Wilson-Cook Medical, Inc., Winston-Salem, N. C.), a 400-cm 0.035-inch guidewire was passed through the access catheter into the duodenal lumen. The original access catheter was then replaced over this guidewire by the 350-cm long 6 F Teflon tube (both long wire and Teflon tube constitute the "guide system"). A front-viewing endoscope was passed orally into the duodenum and retrieved the guide system and pulled it well out of the patient's mouth a sufficient distance to accommodate the length of the stent and the coaxial pushing tube which was threaded over the guide system. While the endoscopist pulled out the guide system, the radiologist fed it in percutaneously under fluoroscopic control to minimize tissue damage. Liberal application of sterile silicone was used to facilitate the stent passing over the guide system as the stent was pushed into the duodenum. Intra-gastric slack in the guide system was taken out, leaving only the fluoroscopically visible loop in the guide as it passes down the bile ducts and up the descending duodenum into the stomach. The caudal point of this loop identifies the locus of the ampulla. While both ends of the guide system were held firm, the endoscopist advanced the stent through the obstruction using the pusher tube. After positioning the stent, the pusher was held firmly against the stent as the guide system was pulled out through the patient's mouth. A short 6 F catheter was advanced over the retreating guidewire into the intra-hepatic ducts and VOLUME 38, NO.4, 1992
Figure 1. A, Upper gastrointestinal barium radiograph shows post-operative Whipple anatomy. Arrow denotes afferent' bowel loop. B, Immediately following stent placement, contrast via percutaneous catheter outlines stent (short arrow) and biliary-enteric anastamosis (long arrow). 499
and November 1990, the patient underwent a series of infusions of 5-fluorouracil with radiation therapy to the hepatic bed for presumed recurrent tumor. Shortly thereafter he was admitted with cholangitis and an emergency percutaneous external drainage catheter was placed. Transcatheter cytology brushings were negative. It was decided to internalize this external drain since the obstruction persisted and there was a likelihood that the externalized drain could become dislodged. Thus, an 11.5 F 5-cm Cotton-Leung stent was again placed by modifying the PEBS method (Fig. 1B). Since the ampullary-duodenal anatomy was surgically altered, the percutaneous guide system was passed toward the gastric remnant close enough to be seen by the endoscopist. There was sufficient residual contrast material from the percutaneous entry procedure to fluoroscopically estimate stent length and locate the site of stenosis. Bilirubin returned to normal and cholangitis resolved. In February 1991, the patient was readmitted with cholangitis. After a course of intravenous antibiotics, he was also committed to chronic oral antibiotic therapy as an outpatient. Despite this regimen, he was readmitted in late March 1991 with cholangitis. The stent was removed by snaring its intestinal end from a distance, using a forward-viewing endoscope. The lumen of the retrieved stent was occluded with a biofilm which grew Enterococcus. His bilirubin, alkaline phosphatase, and transaminases became normal after courses of systemic antibiotics. He remains well at the writing of this report, 16 months post-Whipple resection.
DISCUSSION Non-surgical stenting can relieve malignant jaundice in patients who are frail, have unresectable tumor, or malignant involvement of intra-abdominal structures which would preclude surgical biliary-enteric bypass. Some endoscopists suggest that endoscopic biliary stenting may result in less procedure-related morbidity and mortality and a shorter post-procedure hospitalization than surgical biliary bypass. 9 ,10 We previously described a small series of patients with recurrent malignant biliary obstruction after failed bilio-enteric bypass surgery who were palliated with a modified version of the combined or PEBS method using a front-viewing endoscope. 5 We also used this procedure in patients with Billroth II and Roux-en-Y bowel anatomy,l1 and in a patient whose stenotic duodenum would not allow passage of a duodenoscopeY Nevertheless, obstructive jaundice after Whipple resection poses a challenge to all involved in the care of the patient, and retrograde endobiliary stenting in this context has not been previously described. The initial problem lies in distinguishing a fibrotic stricture at the site of bilio-enteric anastomosis from recurrent malignant obstruction. Percutaneous transhepatic cholangiography can be used to image the problematic anatomy, but the success of therapeutic measures executed via this route depends on the nature of the obstruction (benign or malignant), adequate bile duct distention, and the absence 500
of post-procedure complications. Our experience and that of others show that antegrade percutaneous transhepatic biliary therapy, such as internal stenting and external draining, can result in significant morbidity and mortality, mostly related to trauma to the hepatic parenchyma or migration of the drain catheterY Those patients with the external-internal draining catheter can have painful irritation at the site of percutaneous entry. Altered bowel anatomy or long afferent bowel loops hinder endoscopic access to the bilio-enteric anastomosis site, making retrograde biliary therapy difficult or impossible. Even in the rare instance where endobiliary access might be achieved, the guidewire can easily slip out of the bile duct during coaxial retrograde passage of a stent or dilator. In our patient, the post-Whipple anatomy precluded use of a side-viewing endoscope for biliary therapy, but a frontviewing endoscope could easily "rendezvous" with the percutaneous guiding system passing through the tumor into the bowel lumen. Direct, fixed control over both the percutaneous and per-oral ends of the guide system allowed rapid and successful retrograde stent placement using fluoroscopic guidance, and prevented frustrating guidewire slippage. In addition to its usefulness in patients with altered anatomy and having full control of both ends of the guidewire, the PEBS method has further advantages over other methods of combined procedure; since the stent does not need to pass through the endoscope channel, its caliber is not limited to 10 F; indeed 11.5 or 14 F stents can be placed using this PEBS technique. 2 Larger diameter stents may result in a slower clogging rate than those of smaller diameterY After Whipple resection in the absence of an intact ampulla, there is no need to perform a sphincterotomy prior to stent placement. 4 Clogging of internal biliary stents with resultant cholangitis is a major problem facing clinicians and investigators. 15 ,16 Prophylactic endoscopic stent change is usually performed every 2 or 3 months to obviate its clogging with biofilm. However, in our patient, altered and limited access to the endoprosthesis prevented our use of currently available stentchanging kits. When the stent was removed from our patient, we anticipated that a repeat PEBS would be needed, but he has not experienced recurrent biliary obstruction in over 5 months. In this patient, with a benign stricture, the endoprosthesis probably served as an indwelling dilator as well as an internal drain, allowing the patient to remain well after its removal.
REFERENCES 1. Cello JP. Carcinoma of the pancreas. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal disease. Philadelphia: WB Saunders, 1989:1872-82. 2. Gastrointestinal Tumor Study Group. Further evidence of effective adjuvant combined radiation and chemotherapy follow-
GASTROINTESTINAL ENDOSCOPY
3. 4. 5. 6. 7. 8. 9.
ing curative resection of pancreatic cancer. Cancer 1987;59:2006-10. Pliam MB, ReMine WHo Further evaluation of total pancreatectomy. Arch Surg 1975;110:506-12. Tsang TK, Crampton AR, Bernstein JR, Ramos SR, Wieland JM. Percutaneous-endoscopic biliary stent placement. Ann Intern Med 1987;106:389-92. Tsang TK, Crampton AR, Bernstein JR, Buto SK, Cahan JA. Percutaneous-endoscopic biliary stenting in patients with failed surgical bypass. Am J Med 1990;88:344-8. Speer AG, Cotton PB, Russell CG, et al. Randomized trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57-62. Dowsett JR, Vaira D, Hatfield ARW, et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology 1989;96:1180-6. Cunningham JR. Endoscopic palliation for jaundice associated with malignant biliary obstruction. J SC Med Assoc 1986;82:687-91. Dowsett JF, Russell RCG, Hatfield ARW, et al. Malignant obstructive jaundice: a prospective randomized trial of bypass surgery versus endoscopic stenting. Gastroenterology 1989;96:A128.
Polyarteritis nodosa of the gastrointestinal tract with endoscopically documented duodenal and jejunal ulceration Diane H. Williams, Christianne D. Kratka, J. Peter Bonafede, Ronald M. Katon,
DO MD MD MD
Polyarteritis nodosa (PAN) is a multisystem disease characterized by a necrotizing vasculitis of small and medium-sized arteries.l.2 The full-thickness inflammation can lead to arterial thrombosis or aneurysmal dilation. There is a subset of patients in whom hepatitis B appears to be etiologic. 3 • 4 The association of PAN with hepatitis B, however, has not been shown to alter the clinical course or treatment response of the vasculitis. 1 The disease may be rapidly fatal when not recognized and treated. Necrotizing enterocolitis and bowel infarction are recognized complications of PAN. 5 ,6 Gastrointestinal infarction, hemorrhage, or perforation secondary to PAN is associated with mortality.1 Aggressive immunosuppression may modify the natural history of the disease, 7 although progression despite maximal therapy may occur. Angiography is the cornerstone of diagnosis. Although the microaneurysms are characteristic, gastrointestinal and hepatobiliary involvement may be present in the face of a normal arteriogram. 8 Hence, in a patient in whom
From the Department of Medicine, Division of Gastroenterology and Division of Rheumatology, Oregon Health Sciences University, Portland, Oregon. Reprint requests: Ronald M. Katon, MD, Division of Gastroenterology, L-461, Oregon Health Sciences University, 3181 S. W. Sam Jackson Park Road, Portland, Oregon 97201. VOLUME 38, NO.4, 1992
10. Andersen JR, Sorensen SM, Kruse A, Rokkjaer M, Matzen P. Randomized trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989;30:1132-5. 11. Tsang TK, Crampton AR, Meiselman MS, Desai TK, Bernstein JR. Percutaneous-endoscopic biliary stent placement for Billroth II and total gastrectomy with Roux-en-Y enteroenterostomy. Gastrointest Endosc 1988;34:45-7. 12. Buto SK, Tsang TK, Crampton AR, Berlin G. Nonsurgical bypass of malignant duodenal and biliary obstruction. Gastrointest Endosc 1990;36:518-20. 13. Dooley JS, Dick R, George P, Kirk RM, Hobbs KE, Sherlock S. Percutaneous transhepatic endoprosthesis for bile duct obstruction: complications and results. Gastroenterology 1984;86:905-9. 14. Speer AG, Cotton PB, Macrae KD. Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge. Gastrointest Endosc 1988;34:412-7. 15. Leung JWC, Ling TKW, King JLS, Vallance-Owen J. The role of bacteria in the blockage of biliary stents. Gastrointest Endosc 1988;34:19-22. 16. Speer AG, Cotton PB, Rode J, et al. Biliary stent blockage with bacterial biofilm. Ann Intern Med 1988;108:546-53.
the diagnosis of PAN is suspected, histologic confirmation should follow negative arteriography. We present two cases of polyarteritis nodosa with primarily gastrointestinal manifestations diagnosed at esophagogastroduodenoscopy (EGD). CASE 1
A 50-year-old alcoholic man, with a history of intravenous drug abuse and chronic hepatitis B, was initially evaluated for a benign antral ulcer that responded to ranitidine therapy. Hepatitis B surface antigenemia with positive antibody to hepatitis B core antigen and negative antibody to hepatitis B surface antigen had been present for 5 years. Four years later he presented with persistent epigastric pain unresponsive to antacids or H2 blocker therapy. He also complained of nausea, vomiting, and a 10-lb weight loss. Repeat EGD revealed a recurrent, benign gastric ulcer on the lesser curvature. He failed to respond to medical management and underwent vagotomy, antrectomy, and gastrojejunostomy. Histology of the antral ulcer demonstrated the presence of PAN. Visceral angiography confirmed the diagnosis. Prednisone (80 mg orally daily) and cyclophosphamide (500 mg intravenously) for three doses was initiated, and he was discharged symptomatically improved taking prednisone (40 mg daily). Two weeks later he presented with worsening abdominal pain, orthostatic hypotension, and melena. His hematocrit was 15.7%. He had a diffusely tender abdomen, but bowel sounds were present and he did not have rebound tenderness or involuntary guarding. He was unclear as to whether or not he had continued to take his immunosuppressive therapy. He was transfused with 6 units of packed red blood cells. EGD revealed extensive, deep, serpiginous jejunal ulcers which extended at least 30 cm into the efferent limb. Histology of the ulcers revealed acute inflammation. Angiography disclosed further progression of PAN, now with 501
irradiation is an option which should be considered in the management of malignant blockage of metal stents in those patients likely to survive long enough to otherwise require frequent endoscopic intervention.
REFERENCES 1. Speer AG, Russell CG, Hatfield ARW, et al. Randomized trial
2. 3. 4.
5.
6.
7.
8. 9.
10. 11. 12.
of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57-62. Sohendra N, Grimm H, Berger B, Nam VC. Malignant jaundice: results of diagnostic and therapeutic endoscopy. World J Surg 1989;13:171-7. Speer AG, Cotton PB, Macrae KD. Endoscopic management of biliary obstruction-Stents of 10 F are preferable to stents of 8 F gauge. Gastrointest Endosc 1988;34:412-7. Fockens P, Cheng J, Coene PPLO, Huibregtse K. Endoscopic treatment of biliary strictures with an expandable metal stent; 6-month follow-up [Abstract), World Congress of Gastroenterology, Sydney, Australia, 1990. Neuhaus H, Hagenmuller F, Classen M. Percutaneous transhepatic and endoscopic transpapillary implantation of selfexpanding biliary stents [Abstract]. World Congress of Gastroenterology, Sydney, Australia, 1990. Williams SJ, Carr-Locke D, Cremer M, et al. Self-expanding metal stents (Wallstent) in the endoscopic palliation of malignant biliary obstruction [Abstract]. World Congress of Gastroenterology, Sydney, Australia, 1990. Cremer M, Deviere J, Sugai B, Baize M. Expandable biliary metal stents for malignancies: endoscopic insertion and diathermic cleansing for tumor ingrowth. Gastrointest Endosc 1990;6:451-7. Levitt MD, Laurence BH, Cameron F, Klemp PFB. Transpapillary iridium-192 in the treatment of malignant bile duct obstruction. Gut 1988;29:149-52. Huibregtse K, Cheng J, Coene PPLO, Fockens P, Tytgat GNJ. Endoscopic placement of expandable metal stents for biliary strictures-a preliminary report on experience with 33 patients. Endoscopy 1989;21:280-2. Meyers WC, Jones RS. Internal radiation for bile duct cancer. World J Surg 1988;12:99-104. Laurence BH. Iridium-192 irradiation of biliary tract malignancy. In: Jacobson 1M, ed. ERCP: diagnostic and therapeutic applications. New York: Elsevier, 1989:239-50. Moertel CG, Frytak S, Hahn RG, et al. Therapy of locally unresectable pancreatic carcinoma: a randomised comparison of high dose (6,000 rads) radiation alone, moderate dose radiation (4,000 rads + 5 fluorouracil) and high dose radiation + 5 fluorouracil. Cancer 1981;48:1705-10.
Case Re po rts Percutaneous endoscopic biliary stent placement after Whipple resection Stephen K. Buto, MD Tat-Kin Tsang, MD Arthur R. Crampton, MD
Pancreatic carcinoma generally carries a very poor prognosis. Surgical cure is usually attempted in fit From the Gastrointestinal Laboratory, Evanston Hospital, Evanston, IL. Reprint requests: Tat-Kin Tsang, MD, c/o Gastrointestinal Laboratory, Evanston Hospital, 2650 Ridge Avenue, Evanston, IL 60201.
498
patients who have evidence of localized resectable pancreatic carcinoma, yet only 10% of patients have potentially curable disease at the time of clinical presentation. I In spite of extensive operative exploration, including sampling of regional lymph nodes, microscopic evidence of malignant spread can go undetected. Although some patients who undergo a Whipple resection (partial pancreatectomy, en bloc duodenectomy and cholecystectomy, coupled with choledocho-, pancreatico-, and gastroenterostomy) experience obstructive jaundice due to recurrent maligGASTROINTESTINAL ENDOSCOPY
nancy, the tumor debulking provides a longer diseasefree interval, especially when coupled with adjuvant radiation and chemotherapy.2 In 5 to 10% of postWhipple patients, recurrent obstructive jaundice as a late post-operative complication is caused by stricture at the bilio-enteric anastomosis, requiring surgical reconstruction. 3 Whether benign or malignant, there are few non-surgical options for restoring biliary drainage in patients with recurrent obstructive jaundice after Whipple resection, aside from percutaneous external drainage. Herein, we describe the internal biliary drainage and dilation of a stricture at a bilioenteric anastomosis after a Whipple resection for pancreatic carcinoma.
was used to conduct contrast material to visualize the position and patency of the stent. Later, at laparotomy, a needle aspirate of the pancreatic head mass was interpreted as mucinous cystadenocarcinoma, and a Whipple resection was performed (Fig. 1A). However, final pathologic diagnosis of the resected specimen revealed a well-differentiated adenocarcinoma in the pancreatic head and in only 1 of 10 peripancreatic lymph nodes. The patient's post-operative course was complicated by the development of multiple hepatic abscesses. Enterococcus iaecalis and Staphylococcus epidermidis were isolated from blood cultures and from the abscesses. Abdominal CT revealed progressive intrahepatic bile duct dilation. In October
CASE REPORT
A 58-year-old man presented in April 1990 with painless jaundice. CT demonstrated intra-hepatic and extra-hepatic bile duct distention and a prominent pancreatic head but no distinct mass. ERCP revealed a "double duct" sign, but a guidewire could not be passed through the biliary obstruction in a retrograde manner, therefore a 7-cm 11.5 F CottonLeung biliary stent was placed using the combined percutaneous endoscopic biliary stenting (PEBS) method previously described. 4- 1o Approaching from the mid-axillary line below the costophrenic angle, a Chiba-type 22-gauge needle was placed into the dilated intra-hepatic bile ducts. Using a coaxial entry system (Acustick; Meditech, Watertown, Mass.) a 6 F catheter was passed through the tumor into the duodenum. A measuring guidewire was placed and centimeter divisions counted between anatomical points above the stenosis and below the ampulla. An 11.5 F stent was selected 1.0 em shorter than the length of the measured stenosis. From a preassembled commercially available kit (CT-PEPS combined procedure kit; Wilson-Cook Medical, Inc., Winston-Salem, N. C.), a 400-cm 0.035-inch guidewire was passed through the access catheter into the duodenal lumen. The original access catheter was then replaced over this guidewire by the 350-cm long 6 F Teflon tube (both long wire and Teflon tube constitute the "guide system"). A front-viewing endoscope was passed orally into the duodenum and retrieved the guide system and pulled it well out of the patient's mouth a sufficient distance to accommodate the length of the stent and the coaxial pushing tube which was threaded over the guide system. While the endoscopist pulled out the guide system, the radiologist fed it in percutaneously under fluoroscopic control to minimize tissue damage. Liberal application of sterile silicone was used to facilitate the stent passing over the guide system as the stent was pushed into the duodenum. Intra-gastric slack in the guide system was taken out, leaving only the fluoroscopically visible loop in the guide as it passes down the bile ducts and up the descending duodenum into the stomach. The caudal point of this loop identifies the locus of the ampulla. While both ends of the guide system were held firm, the endoscopist advanced the stent through the obstruction using the pusher tube. After positioning the stent, the pusher was held firmly against the stent as the guide system was pulled out through the patient's mouth. A short 6 F catheter was advanced over the retreating guidewire into the intra-hepatic ducts and VOLUME 38, NO.4, 1992
Figure 1. A, Upper gastrointestinal barium radiograph shows post-operative Whipple anatomy. Arrow denotes afferent' bowel loop. B, Immediately following stent placement, contrast via percutaneous catheter outlines stent (short arrow) and biliary-enteric anastamosis (long arrow). 499
and November 1990, the patient underwent a series of infusions of 5-fluorouracil with radiation therapy to the hepatic bed for presumed recurrent tumor. Shortly thereafter he was admitted with cholangitis and an emergency percutaneous external drainage catheter was placed. Transcatheter cytology brushings were negative. It was decided to internalize this external drain since the obstruction persisted and there was a likelihood that the externalized drain could become dislodged. Thus, an 11.5 F 5-cm Cotton-Leung stent was again placed by modifying the PEBS method (Fig. 1B). Since the ampullary-duodenal anatomy was surgically altered, the percutaneous guide system was passed toward the gastric remnant close enough to be seen by the endoscopist. There was sufficient residual contrast material from the percutaneous entry procedure to fluoroscopically estimate stent length and locate the site of stenosis. Bilirubin returned to normal and cholangitis resolved. In February 1991, the patient was readmitted with cholangitis. After a course of intravenous antibiotics, he was also committed to chronic oral antibiotic therapy as an outpatient. Despite this regimen, he was readmitted in late March 1991 with cholangitis. The stent was removed by snaring its intestinal end from a distance, using a forward-viewing endoscope. The lumen of the retrieved stent was occluded with a biofilm which grew Enterococcus. His bilirubin, alkaline phosphatase, and transaminases became normal after courses of systemic antibiotics. He remains well at the writing of this report, 16 months post-Whipple resection.
DISCUSSION Non-surgical stenting can relieve malignant jaundice in patients who are frail, have unresectable tumor, or malignant involvement of intra-abdominal structures which would preclude surgical biliary-enteric bypass. Some endoscopists suggest that endoscopic biliary stenting may result in less procedure-related morbidity and mortality and a shorter post-procedure hospitalization than surgical biliary bypass. 9 ,10 We previously described a small series of patients with recurrent malignant biliary obstruction after failed bilio-enteric bypass surgery who were palliated with a modified version of the combined or PEBS method using a front-viewing endoscope. 5 We also used this procedure in patients with Billroth II and Roux-en-Y bowel anatomy,l1 and in a patient whose stenotic duodenum would not allow passage of a duodenoscopeY Nevertheless, obstructive jaundice after Whipple resection poses a challenge to all involved in the care of the patient, and retrograde endobiliary stenting in this context has not been previously described. The initial problem lies in distinguishing a fibrotic stricture at the site of bilio-enteric anastomosis from recurrent malignant obstruction. Percutaneous transhepatic cholangiography can be used to image the problematic anatomy, but the success of therapeutic measures executed via this route depends on the nature of the obstruction (benign or malignant), adequate bile duct distention, and the absence 500
of post-procedure complications. Our experience and that of others show that antegrade percutaneous transhepatic biliary therapy, such as internal stenting and external draining, can result in significant morbidity and mortality, mostly related to trauma to the hepatic parenchyma or migration of the drain catheterY Those patients with the external-internal draining catheter can have painful irritation at the site of percutaneous entry. Altered bowel anatomy or long afferent bowel loops hinder endoscopic access to the bilio-enteric anastomosis site, making retrograde biliary therapy difficult or impossible. Even in the rare instance where endobiliary access might be achieved, the guidewire can easily slip out of the bile duct during coaxial retrograde passage of a stent or dilator. In our patient, the post-Whipple anatomy precluded use of a side-viewing endoscope for biliary therapy, but a frontviewing endoscope could easily "rendezvous" with the percutaneous guiding system passing through the tumor into the bowel lumen. Direct, fixed control over both the percutaneous and per-oral ends of the guide system allowed rapid and successful retrograde stent placement using fluoroscopic guidance, and prevented frustrating guidewire slippage. In addition to its usefulness in patients with altered anatomy and having full control of both ends of the guidewire, the PEBS method has further advantages over other methods of combined procedure; since the stent does not need to pass through the endoscope channel, its caliber is not limited to 10 F; indeed 11.5 or 14 F stents can be placed using this PEBS technique. 2 Larger diameter stents may result in a slower clogging rate than those of smaller diameterY After Whipple resection in the absence of an intact ampulla, there is no need to perform a sphincterotomy prior to stent placement. 4 Clogging of internal biliary stents with resultant cholangitis is a major problem facing clinicians and investigators. 15 ,16 Prophylactic endoscopic stent change is usually performed every 2 or 3 months to obviate its clogging with biofilm. However, in our patient, altered and limited access to the endoprosthesis prevented our use of currently available stentchanging kits. When the stent was removed from our patient, we anticipated that a repeat PEBS would be needed, but he has not experienced recurrent biliary obstruction in over 5 months. In this patient, with a benign stricture, the endoprosthesis probably served as an indwelling dilator as well as an internal drain, allowing the patient to remain well after its removal.
REFERENCES 1. Cello JP. Carcinoma of the pancreas. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal disease. Philadelphia: WB Saunders, 1989:1872-82. 2. Gastrointestinal Tumor Study Group. Further evidence of effective adjuvant combined radiation and chemotherapy follow-
GASTROINTESTINAL ENDOSCOPY
3. 4. 5. 6. 7. 8. 9.
ing curative resection of pancreatic cancer. Cancer 1987;59:2006-10. Pliam MB, ReMine WHo Further evaluation of total pancreatectomy. Arch Surg 1975;110:506-12. Tsang TK, Crampton AR, Bernstein JR, Ramos SR, Wieland JM. Percutaneous-endoscopic biliary stent placement. Ann Intern Med 1987;106:389-92. Tsang TK, Crampton AR, Bernstein JR, Buto SK, Cahan JA. Percutaneous-endoscopic biliary stenting in patients with failed surgical bypass. Am J Med 1990;88:344-8. Speer AG, Cotton PB, Russell CG, et al. Randomized trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57-62. Dowsett JR, Vaira D, Hatfield ARW, et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology 1989;96:1180-6. Cunningham JR. Endoscopic palliation for jaundice associated with malignant biliary obstruction. J SC Med Assoc 1986;82:687-91. Dowsett JF, Russell RCG, Hatfield ARW, et al. Malignant obstructive jaundice: a prospective randomized trial of bypass surgery versus endoscopic stenting. Gastroenterology 1989;96:A128.
Polyarteritis nodosa of the gastrointestinal tract with endoscopically documented duodenal and jejunal ulceration Diane H. Williams, Christianne D. Kratka, J. Peter Bonafede, Ronald M. Katon,
DO MD MD MD
Polyarteritis nodosa (PAN) is a multisystem disease characterized by a necrotizing vasculitis of small and medium-sized arteries.l.2 The full-thickness inflammation can lead to arterial thrombosis or aneurysmal dilation. There is a subset of patients in whom hepatitis B appears to be etiologic. 3 • 4 The association of PAN with hepatitis B, however, has not been shown to alter the clinical course or treatment response of the vasculitis. 1 The disease may be rapidly fatal when not recognized and treated. Necrotizing enterocolitis and bowel infarction are recognized complications of PAN. 5 ,6 Gastrointestinal infarction, hemorrhage, or perforation secondary to PAN is associated with mortality.1 Aggressive immunosuppression may modify the natural history of the disease, 7 although progression despite maximal therapy may occur. Angiography is the cornerstone of diagnosis. Although the microaneurysms are characteristic, gastrointestinal and hepatobiliary involvement may be present in the face of a normal arteriogram. 8 Hence, in a patient in whom
From the Department of Medicine, Division of Gastroenterology and Division of Rheumatology, Oregon Health Sciences University, Portland, Oregon. Reprint requests: Ronald M. Katon, MD, Division of Gastroenterology, L-461, Oregon Health Sciences University, 3181 S. W. Sam Jackson Park Road, Portland, Oregon 97201. VOLUME 38, NO.4, 1992
10. Andersen JR, Sorensen SM, Kruse A, Rokkjaer M, Matzen P. Randomized trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989;30:1132-5. 11. Tsang TK, Crampton AR, Meiselman MS, Desai TK, Bernstein JR. Percutaneous-endoscopic biliary stent placement for Billroth II and total gastrectomy with Roux-en-Y enteroenterostomy. Gastrointest Endosc 1988;34:45-7. 12. Buto SK, Tsang TK, Crampton AR, Berlin G. Nonsurgical bypass of malignant duodenal and biliary obstruction. Gastrointest Endosc 1990;36:518-20. 13. Dooley JS, Dick R, George P, Kirk RM, Hobbs KE, Sherlock S. Percutaneous transhepatic endoprosthesis for bile duct obstruction: complications and results. Gastroenterology 1984;86:905-9. 14. Speer AG, Cotton PB, Macrae KD. Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge. Gastrointest Endosc 1988;34:412-7. 15. Leung JWC, Ling TKW, King JLS, Vallance-Owen J. The role of bacteria in the blockage of biliary stents. Gastrointest Endosc 1988;34:19-22. 16. Speer AG, Cotton PB, Rode J, et al. Biliary stent blockage with bacterial biofilm. Ann Intern Med 1988;108:546-53.
the diagnosis of PAN is suspected, histologic confirmation should follow negative arteriography. We present two cases of polyarteritis nodosa with primarily gastrointestinal manifestations diagnosed at esophagogastroduodenoscopy (EGD). CASE 1
A 50-year-old alcoholic man, with a history of intravenous drug abuse and chronic hepatitis B, was initially evaluated for a benign antral ulcer that responded to ranitidine therapy. Hepatitis B surface antigenemia with positive antibody to hepatitis B core antigen and negative antibody to hepatitis B surface antigen had been present for 5 years. Four years later he presented with persistent epigastric pain unresponsive to antacids or H2 blocker therapy. He also complained of nausea, vomiting, and a 10-lb weight loss. Repeat EGD revealed a recurrent, benign gastric ulcer on the lesser curvature. He failed to respond to medical management and underwent vagotomy, antrectomy, and gastrojejunostomy. Histology of the antral ulcer demonstrated the presence of PAN. Visceral angiography confirmed the diagnosis. Prednisone (80 mg orally daily) and cyclophosphamide (500 mg intravenously) for three doses was initiated, and he was discharged symptomatically improved taking prednisone (40 mg daily). Two weeks later he presented with worsening abdominal pain, orthostatic hypotension, and melena. His hematocrit was 15.7%. He had a diffusely tender abdomen, but bowel sounds were present and he did not have rebound tenderness or involuntary guarding. He was unclear as to whether or not he had continued to take his immunosuppressive therapy. He was transfused with 6 units of packed red blood cells. EGD revealed extensive, deep, serpiginous jejunal ulcers which extended at least 30 cm into the efferent limb. Histology of the ulcers revealed acute inflammation. Angiography disclosed further progression of PAN, now with 501