- Email: [email protected]
Piercing of the ampulla via the stent-in-stent biliary metal stent technique
VideoGIE
The PD stone was seen, confirming the EUS findings (Fig. 1B). Total pancreatectomy was avoided. The patient was discharged a few days after surgery. He is being monitored by periodic imaging and is doing well while taking pancreatic enzyme supplements.
Toufic Kachaamy, MD, Cancer Treatment Centers of America, Phoenix, Arizona, Wajeeh Salah, MD, Mayo Clinic, Scottsdale, Arizona, Ivana Dzeletovic, MD, Beth Israel Deaconess, Boston, Massachusetts, Nabil Wasif, MD, Edwyn Harrison, MD, Douglas O. Faigel, MD, Rahul Pannala, MD, Mayo Clinic, Scottsdale, Arizona, USA
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
http://dx.doi.org/10.1016/j.gie.2014.07.024
Piercing of the ampulla via the stent-in-stent biliary metal stent technique
Figure 1. Endoscopic view of stents protruding from both the proximal papilla and the ampullary orifice.
A 67-year-old man with a locally unresectable pancreatic neuroendocrine tumor and obstructive jaundice was treated with placement of an uncovered metal biliary stent. After stent placement, the patient developed persistent pain and requested stent removal. A fully covered stent was subsequently placed within the original stent to induce pressure necrosis of tissue ingrowth and allow for removal of both stents. However, the patient’s pain resolved, and
Figure 2. Fluoroscopic view of stents protruding from both the proximal papilla and the ampullary orifice.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
both stents were left in situ at his request. Six months later, the patient was seen with mild epigastric and/or right upper quadrant pain and intermittent fevers, concerning for cholangitis. The patient was referred for urgent ERCP. On endoscopy (Fig. 1), the stents were seen emanating from both the proximal papillary tissue and the ampullary orifice, whereas fluoroscopy (Fig. 2) confirmed that the stents were held in place by a thin rim of ampullary tissue, thus piercing the ampulla. Because of persistent pressure,
460 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 2 : 2015
www.giejournal.org
VideoGIE
the stents had perforated the lateral intraduodenal segment of the bile duct across the proximal papilla into the duodenum, thus creating a choledochoduodenal fistula. The stents were removed together by using a snare, and because of a persistent stricture of the distal bile duct, a partially covered biliary stent was placed via the fistula, with resolution of obstruction (Video 1, available online at www.giejournal.org).
disclosed no financial relationships relevant to this publication. Rabindra R. Watson, MD, Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, Christopher M. Hamerski, MD, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, Venkataraman Muthusamy, MD, FACG, FASGE, Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
DISCLOSURE V. Muthusamy is a consultant for Boston Scientific Corporation, BaroNova, and Covidien. All other authors
http://dx.doi.org/10.1016/j.gie.2014.05.299
Endoscopic removal of a large common bile duct stone: more than one way to skin a cat
Figure 1. Cholangiogram demonstrating a large “cat’s eye” calculus in the distal common bile duct.
A 69-year-old man presented for treatment of choledocholithiasis. His medical history included ascending cholangitis related to choledocholithiasis and Billroth II surgery for peptic ulcer disease. An ERCP demonstrated a filling defect in the common bile duct. A 10F, 7-cm plastic stent was placed for decompression. The patient was referred for further intervention. A standard duodenoscope was passed into the afferent limb to the level of
the papilla. A biliary sphincterotomy was performed. Cholangiography (Fig. 1) demonstrated a 15-mm stone, known as a “cat’s eye” calculus, in the mid-common duct, with a central surgical clip from his prior cholecystectomy. The biliary stent was retrieved. Attempts to fracture and remove the stone by using a 15-mm dilating balloon and mechanical lithotriptor were unsuccessful. Ultimately, a singleballoon enteroscope with overtube was passed to the
www.giejournal.org
Volume 81, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 461
The PD stone was seen, confirming the EUS findings (Fig. 1B). Total pancreatectomy was avoided. The patient was discharged a few days after surgery. He is being monitored by periodic imaging and is doing well while taking pancreatic enzyme supplements.
Toufic Kachaamy, MD, Cancer Treatment Centers of America, Phoenix, Arizona, Wajeeh Salah, MD, Mayo Clinic, Scottsdale, Arizona, Ivana Dzeletovic, MD, Beth Israel Deaconess, Boston, Massachusetts, Nabil Wasif, MD, Edwyn Harrison, MD, Douglas O. Faigel, MD, Rahul Pannala, MD, Mayo Clinic, Scottsdale, Arizona, USA
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
http://dx.doi.org/10.1016/j.gie.2014.07.024
Piercing of the ampulla via the stent-in-stent biliary metal stent technique
Figure 1. Endoscopic view of stents protruding from both the proximal papilla and the ampullary orifice.
A 67-year-old man with a locally unresectable pancreatic neuroendocrine tumor and obstructive jaundice was treated with placement of an uncovered metal biliary stent. After stent placement, the patient developed persistent pain and requested stent removal. A fully covered stent was subsequently placed within the original stent to induce pressure necrosis of tissue ingrowth and allow for removal of both stents. However, the patient’s pain resolved, and
Figure 2. Fluoroscopic view of stents protruding from both the proximal papilla and the ampullary orifice.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
both stents were left in situ at his request. Six months later, the patient was seen with mild epigastric and/or right upper quadrant pain and intermittent fevers, concerning for cholangitis. The patient was referred for urgent ERCP. On endoscopy (Fig. 1), the stents were seen emanating from both the proximal papillary tissue and the ampullary orifice, whereas fluoroscopy (Fig. 2) confirmed that the stents were held in place by a thin rim of ampullary tissue, thus piercing the ampulla. Because of persistent pressure,
460 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 2 : 2015
www.giejournal.org
VideoGIE
the stents had perforated the lateral intraduodenal segment of the bile duct across the proximal papilla into the duodenum, thus creating a choledochoduodenal fistula. The stents were removed together by using a snare, and because of a persistent stricture of the distal bile duct, a partially covered biliary stent was placed via the fistula, with resolution of obstruction (Video 1, available online at www.giejournal.org).
disclosed no financial relationships relevant to this publication. Rabindra R. Watson, MD, Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, Christopher M. Hamerski, MD, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, Venkataraman Muthusamy, MD, FACG, FASGE, Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
DISCLOSURE V. Muthusamy is a consultant for Boston Scientific Corporation, BaroNova, and Covidien. All other authors
http://dx.doi.org/10.1016/j.gie.2014.05.299
Endoscopic removal of a large common bile duct stone: more than one way to skin a cat
Figure 1. Cholangiogram demonstrating a large “cat’s eye” calculus in the distal common bile duct.
A 69-year-old man presented for treatment of choledocholithiasis. His medical history included ascending cholangitis related to choledocholithiasis and Billroth II surgery for peptic ulcer disease. An ERCP demonstrated a filling defect in the common bile duct. A 10F, 7-cm plastic stent was placed for decompression. The patient was referred for further intervention. A standard duodenoscope was passed into the afferent limb to the level of
the papilla. A biliary sphincterotomy was performed. Cholangiography (Fig. 1) demonstrated a 15-mm stone, known as a “cat’s eye” calculus, in the mid-common duct, with a central surgical clip from his prior cholecystectomy. The biliary stent was retrieved. Attempts to fracture and remove the stone by using a 15-mm dilating balloon and mechanical lithotriptor were unsuccessful. Ultimately, a singleballoon enteroscope with overtube was passed to the
www.giejournal.org
Volume 81, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 461