Biliary - ERCP after Pancreaticoduodenectomy
Comments:
1. Following pancreaticoduodenectomy there are two basic anatomical arrangements for the anastomoses. On the left is depicted the classic operation described by Whipple where there is a partial gastrectomy, a side-to-side gastrojejunostomy and the afferent loop, often very long, carries the hepaticojejunostomy and pancreaticojejunostomy with a variety of placements. On the right is the newer pylorus-preserving pancreaticoduodenectomy where there is no gastrectomy but an end-to-side pylorojejunostomy with the afferent loop carrying the hepticojejunostomy about halfway and the pancreticojejunostomy at the apex of the loop as shown.
2. Here are three patients after pancreaticoduodenectomy with different pancreatic or biliary problems exemplifying some of the difficulties encountered in attempting ERCP after this operation.
3. This first example, with suspected recurrent cholangitis, is a classic Whipple with a gastroejunostomy and there is great difficulty entering the afferent loop which is nearly always the more difficult of the two. A standard duodenoscope is being used but it is too flexible to advance into the afferent loop despite external manual compression and various stiffening devices passed through the accessory channel. Here an extraction balloon has been advanced into the afferent loop over a guidewire and injection of contrast outlines the loop and a dilated biliary tree. Contrast drains rapidly. Finally, a 10 French diameter cholangioscope is passed over a guidewire into the bile duct to confirm patency of the bilioenteric anastomosis.
4. The second example, with recurrent pancreatitis, shows a pylorus-preserving pancreaticoduodenectomy with successful intubaton of the afferent loop of the pylorojejunostomy with a standard duodenoscope. At the apex of the loop, a thin-walled bulging cystic structure represents a stenosed pancreaticojejunostomy after intravenous secretin injection. The anastomosis is identified on the left side of the mound and a guidewire is placed with the help of a catheter. Subsequent dilation was accomplished and a stent placed.
5. In the last example of a patient with biliary obstruction and recurrent cholangitis after a standard Whipple resection, a small caliber colonoscope is being used after failed attempts with a duodenoscope and a gastroscope with stiffening wire. Using external counter pressure, guided by fluoroscopy, access is gained to the afferent loop and a very stenosed hepaticojejunostomy is identified. Cannulation is achieved with an angled guidewire. Subsequent dilation of the anastomosis was successful.
6. Endoscopic management of pancreatic and biliary problems after pancreaticoduodenectomy is feasible and effective
| Contributed by: |
David Carr-Locke, M.D. Director of Endoscopy Brigham and Women's Hospital |
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Citation: Carr-Locke, D. (Feb 28 2006). Biliary - ERCP after Pancreaticoduodenectomy. The DAVE Project. Retrieved Sep, 6, 2010, from http://daveproject.org/viewfilms.cfm?film_id=360 Times viewed since Feb 2006: 6135 |
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