Advanced Endoscopic Pancreaticobiliary Therapy in Surgically-Altered Enteral Anatomy
Comments: This video will present a series of cases highlighting techniques and devices useful in the endoscopic treatment of pancreaticobiliary disorders in the setting of post-surgical anatomy.
Post-surgical anatomy can present challenges to endoscopic pancreaticobiliary therapy. For example, there can be extensive re-routing to the cannulation site such as in RY anatomy or Bilroth anatomy. Another problem can be the presence of surgical anastomoses as in Whipple's anatomy.
We describe solutions, both old and new, for the following scenarios:
1. Solo navigation to the cannulation site using standard endoscopic equipment, such as pediatric colonoscop, shapelocking overtubes, and helical overtubes
2. Surgically assisted navigation to the cannulation site
3. Upon reaching the cannulation site, Failed cannuklation is more commonly encountered in altered anatomy and can be potentially addressed using perctuaneous and EUS-assisted rendezvous procedures
We begin with solo navigation
Solo navigation
Simple manual pressure with a lead glove can be helpful For negotiating long jejunal limbs encountered in RY patients, and counteracting the loops that inevitably form.
Alternatively, a pediatric colonoscope can be advanced to the papilla to deploy a guidewire over which a duodenoscope can be backloaded.
To negotiate the long jejunal limbs, rigidizable devices such as Shapelock have been utilized to minimize looping. [0:20]
More recently, a helical overtube has been used to navigate bariatric anatomy. The corkscrew orientation of the overtube's outer ridges allows for pleating of the small bowel with a clockwise rotation.
After the Y anastomosis, the biliopancreatic limb is intubated. The pylorus is traversed in retrograde fashion and the remnant stomach explored.
The overtube is advanced over the endoscope and now resides in the duodenum.
Due to insufficient length of the pediatric duodenoscope, the proximal handle of the overtube is cut.
The duodenoscope is then advanced without difficulties to the papilla where sphincterotomy is performed followed by balloon sweep of the biliary tree.
Assisted navigation
Laparoscopic assisted ERCP via a surgically-created gastrotomy can be used to access long, excluded afferent limbs.
Patients requiring repeated ERCPs may benefit from the presence of a perctuaneous gastrostomy or PEG for access. In this RYGB patient requiring several biliary cannulations for debris clearance, a perctuaneous gastrostomy was surgically created. The 26 F gastrostomy tube was removed, and the tract was serially dilated using Hagar dilators to a caliber of 11 mm.
An upper endoscope was advanced to evaluate for perforation or bleeding. Retroflexion in the stomach to evaluate the gastrostomy site was unremarkable. The diagnostic duodenoscope was advanced to the major papilla. A sphincterotomy was created and the biliary tree was later swept with a balloon.
Failed-Cannulation
Cannulation can be difficult in altered anatomy, but several options are possible.
With assistance from interventional radiology, the transhepatic rendezvous procedure involves perctuaneous insertion of a guidewire into the biliary system, and across the ampulla. The guidewire is captures by a snare and permits retrograde cannulation.
The emergence of interventional endoscopic ultrasound has modified the rendezvous procedure by replacing percutaneous access with transgastric access. In this diagram of post-Wipple's anatomy, the PD is cannulated under EUS guidance. A guidewire is then advanced through an echo-needle across the gastric wall and, in this case, into the pancreatic duct. The duodenoscope then performs a rendezvous with the guidewire.
When antegrade passage of the guidewire is not possible, such as with strictures of the pancreaticojejunal anastomosis, EUS can be used to create a stented fistula between the stomach and the main pancreatic duct for retrograde drainage into the stomach.
We describe a modification of this latter technique called the PANK procedure which involved antegrade needle knife access across the anastomotic stricture site to restore antegrade flow. When advancement of the guidewire is not possible, an antegrade needle knife cut is made across the stricture site followed by the antegrade placement of a long stent spanning the small bowel, PD, and stomach. In subsequent procedure, this stent is converted to a larger pancreatico-enteral stent, which is ultimately removed during the 3rd and final procedure after restoration of antegrade PD flow.
This Whipple's patient had a dilated PD from a strictured pancreaticojejunostomy anastomosis.
Following EUS guided access of the PD, a guidewire could not be advanced past the stricture despite repeated attempts.
Under fluoroscopic guidance, a needle knife catheter was advanced over the guidewire and pushed against the duct until indentation of the jejunum was visualized. After making a small antegrade needle knife cut, the guidewire was advanced deeply into the jejunum
The pancreatico jejunotomy was dilated under fluoroscopy. The distal PD and the pancreaticogastotomy were also dilated.
A 7Fr x 15cm pancreatic stent was placed in antegrade fashion to span the jejunum, PD, and stomach. Double drainage of the PD was performed to avoid development of a pancreatic fluid collection.
This stent was later converted to a larger pancreaticojejunal stent, which was ultimately removed. Radiographic studies showed improvement in PD dilation and the patient's pain had resolved.
Summary
In summary, to enhance solo navigation in surgically altered anatomy, we have described the use of a pediatric colonoscope, a rigidizable overtube, and a helical overtube which pleats small bowel.
For assisted navigation, we have described Hagar dilation of a surgically placed gastrostomy or PEG for repeated pancreaticobiliary access.
Finally, for situations of failed cannulation which is more common in altered anatomy, we describe the traditional rendezvous procedure, EUS-guided rendezvous, EUS-assisted retrograde drainage into the stomach, and the pancreatic antegrade needle knife or PANK procedure for restoration of antegrade flow.
Thank you for your attention.
| Contributed by: |
Marvin Ryou, MD Brigham and Women's Hospital |
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Citation: Ryou, M. (Jun 01 2009). Advanced Endoscopic Pancreaticobiliary Therapy in Surgically-Altered Enteral Anatomy. The DAVE Project. Retrieved Sep, 4, 2010, from http://daveproject.org/viewfilms.cfm?film_id=858 Times viewed since Feb 2006: 3334 |
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