Endoscopic retrograde cholangiodilatation: A preliminary report
Timothy G. Lee, MD* Ronald Katon, MD Patrick C. Freeny, MD Sidney C. Henderson, MD Marcia K. Bilbao, MD
University of Oregon Health Sciences Center Departments of Radiology and Internal Medicine (Division of Gastroenterology) Portland, Oregon
Diagnostic endoscopic cannulation of the common bile duct and pancreatic duct (ERCP) is now an established procedure. Equipment and techniques are described in the Iiterature. 5, ' Possible therapeutic applications of ERCP warrant continuing exploration, Sphincterotomy with removal of ·Reprint requests: Timothy G, lee, MD, Department of Radiology, University of Oregon Health Sciences Center, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201. This work was supported in part by the George Alfred Cook Memorial Fund through the Medical Research Foundation of Oregon.
Figure 1. Tightly stenotic common bile duct at site of cho/edochoduodenostomy (arrow).
common duct stones endoscopically has been reported. a The positioning of an indwelling catheter at the time of endoscopy has been described. ' ° Recently, Burhenne 3 presented nonsurgical dilation of a common bile duct stricture through aT-tube To our knowledge, an attempt to dilate a common bile duct stricture endoscopically has not been reported. To share our initial experience is the purpose of this communication. CASE REPORT A 65-year-old woman with obstructive jaundice had a choledochoduodenostomy 23 years earlier. Endoscopic retrograde cholangiography demonstrated a tight stricture of the common bile duct (Figure 1). Using a 5 French Fogarty catheter outrigged to a front-viewing Olympus GIF-D panendoscope (Figure 2), the common bile duct was cannulated, and the inflated balloon was pulled through the stricture several times. At fluoroscopy, the Fogarty balloon was observed to deform as it passed through the stricture (Figure 3). Its compressibility did not allow it to achieve maximum dilatation. The patient experienced no discomfort or complication. At the time, a satisfactory balloon catheter was not available. The stricture was treated surgically 2 weeks later. DISCUSSION Strictures in the biliary ducts are not uncommon and may be associated with calculi, previous surgery, cholangitis, or pancreatitis. Sphincteroplasty or choledochoduodenostomy are often performed to correct the obstruction. Analysis of the surgical literature reveals that these procedures are often performed on elderly, poor risk patients who have had multiple previous biliary or pancreatic operations.',7,1l,15 Postoperative complications are
Figure 2. Fogarty balloon catheter outrigged to a forward viewing panendoscope.
Figure 3. Sequential films of Fogarty balloon passing through a strictured common bile duct: (a) proximal to stricture, (b) entering stricture, (c) deformed by stricture, and (d) distal to stricture. VOLUME 23, NO.3, 1977
171
frequent,·,12 and mortality averages 3%,7,12 Operation for recurrent stricture may be as high as 20%.'3'" Development of a nonoperative, repeatable approach to cholangiopancreatic ductal strictures would be of benefit in high risk patients. Even temporary relief of bi liary obstructions could be useful, as it might permit a period of medical management to improve the patient's condition in preparation for definitive surgery. If necessary, the dilation could be repeated. The efficacy of mechanical dilation of structures in the esophagus' and the experience of Burhenne 3 in dilating biliary strictures through a T-tube suggest that common duct strictures could be treated endoscopically. For our initial attempt, we were forced to outrig the catheter to the panendoscope, because the only Fogarty catheters available to us at the time were too short to pass through the biopsy channel. To avoid outrigging the endoscope, the length of such a catheter should be about 150 cm to 175 cm, which would be ample for use with the standard panendoscopes (working length, 100 cm) or duodenoscopes (working length, 120 cm). The Fogarty balloon proved to be too soft to achieve significant dilation, but a more rigid balloon catheter adaptable to the endoscope, if available, might have been more effective. While the risks of this procedure cannot be firmly estab~ Iished until a large number of cases have been studied, we experienced no difficulties in this first attempt. Furthermore, in the cases of therapeutic instrumentation reported by Burhenne,3 Nakajima et al.,8 and Shapiro and Cotton,'O no complications were reported. The complications of ERCP have been well documented. 2 We feel that endoscopic dilation of common bile duct strictures is feasible. Therapeutic applications ofthe fiberoptic endoscope are of increasing interest to endoscopists, and this paper is submitted to stimulate further investigation in this area. REFERENCES 1. BENSON CD, MUSTARD WT, RAVITCH MM, SNYDER WH, WELCH Kj: Pediatric Surgery. Chicago, Year Book Medical Publishers, 1962, pp. 286 and 293 2. BILBAO MK, DOTTER DT, LEE TG, KATON RM: Complications of endoscopic retrograde cholangiopancreatography (ERCP): Study of 10,000 cases. Gastroenterology 70:314, 1976 3. BURHENNE Hj: Dilatation of biliary tract strictures: a new roentgenologic technique. Radiologia Clin 44: 153, 1975 4. FARRAR T, PAINTER MW, BETZ ETZ R: Choledochoduodenostomy in the treatment of stenosis of the distal common bile duct. Arch Surg 98:442,
1969 5. KATON RM, LEE TG, PARENT jA, BILBAO MK, SMITH FW: Endoscopic retrograde cholangiopancreatography (ERCP): experience with 100 cases; Am I Dig Dis 19:295, 1974 6. McARTHUR MS, LONGMIRE WP jR: Peptic ulcer disease after choledochojejunostomy. Am I Surg 122:155, 1971 7. MADDEN jL, CHUN jY, KANDALAFT S, PAREKH M: Choledochoduodenostomy: an unjustly maligned procedure? Am I Surg 119:45, 1970 8. NAKAJIMA M, KIMOTO K, FUKUMOTO j, IKEHARA H, KAWAI K: Endoscopic sphincterotomy of the ampulla of Vater and removal of common duct stones. Am I Gastroenterol 64:34, 1975 9.01 I: Fiberduodenostomy and endoscopic pancreatocholangiography. Gastrointestinal Endoscopy 17:59, 1970 10. SHAPIRO HA, COTTON PB: Leaving a balloon-tip catheter in the bile duct at duodenoscopy: a new technique for sequential collection of pure bile in man. Lancet 2:13, 1975 11. STUART M, HOERR SO: Late results of side-to-side choledochoduodenostomy and of transduodenal sphincterotomy for benign disease. Am I Surg
123:67, 1972 12. THOMAS CG jR, NICHOLSON CP, OWEN j: Effectiveness of choledochoduodenostomy and transduodenal sphincterotomy in the treatment of benign obstruction of the common bile duct. Am Surg 173:845, 1971 13. WALTERS W, RAMSDELL jA: Study of 308 operations for stricture of the bile ducts. lAMA 171 :872, 1959 14. WALTMAN W (in discussion), SAWYER RB, SAWYER KC: Choledochoduodenostomy for gallstones. Arch Surg 102:308, 1971 15. WHITE TT: Indications for sphincteroplasty as opposed to choledochoduodenostomy. Am I Surg 126:165, 1973
172
Counsel to Authors
GASTROINTESTINAL ENDOSCOPY seeks to publish original papers describing investigations and significant observations relating to the various endoscopic techniques employed in the study of digestive diseases. Descriptions of new instruments or methods, innovative applications of endoscopy, analyses of experience, and extraordinary case reports are welcome subjects. Readers who are piqued or prodded by published articles are encouraged to submit brief comments that the editor may include in the "Reflex" section. Announcements of postgraduate courses, new fac iIities, cooperative stud ies, and other items of interest to endoscopists are invited. Address typescripts and editorial correspondence to the editor. Typescripts should be submitted in duplicate on white paper of standard (8'12 x 11 inches) si;e. All copy, including footnotes, references, and captions, should be double spaced with generous margins. The title page should include the author's name(s), the institution where the work was performed, and the name and address to which requests for reprints should be sent. Illustrations, including photographs and charts, should be submitted in duplicate as glossy prints, not less than 5 x 7 inches, preferably of uniform size. These must be unmounted and clearly labeled on the back, lightly in pencil, to indicate first author's name, figure number, and top of illustration. Radiographs and photographs must be of high contrast for proper reproduction. A reasonable number of pertinent illustrations in black and white can be allowed without charge. Top qual ity endoscopic photographs can be reproduced in color by special arrangement with the editor. References should be indicated by consecutive numbers in the text and enumerated at the end of the paper in the same order. Each reference should conform to the following example: Scope GE, Optic F: What we saw. Gastroenterology 500: 1001, 1962 All authors should be listed (not "et al."). Abbreviations of journal names are to be used as in Index Medicus. Helpful information pertaining to the preparation of scientific articles will be found in Style Manual for Biological Journals, Ed. 3, publ ished by American Institute of Biological Sciences, 3900 Wisconsin Ave., N.W., Washington, DC 20016. Galley proofs will be sent to the author for necessary corrections with the understanding that they are to be promptly returned. Reprints should be ordered when galley proofs are returned. A purchase form will be furnished. Authors are reminded to retain in their own files a copy of the typescript and illustrations submitted.
GASTROINTESTINAL ENDOSCOPY
Timothy G. Lee, MD* Ronald Katon, MD Patrick C. Freeny, MD Sidney C. Henderson, MD Marcia K. Bilbao, MD
University of Oregon Health Sciences Center Departments of Radiology and Internal Medicine (Division of Gastroenterology) Portland, Oregon
Diagnostic endoscopic cannulation of the common bile duct and pancreatic duct (ERCP) is now an established procedure. Equipment and techniques are described in the Iiterature. 5, ' Possible therapeutic applications of ERCP warrant continuing exploration, Sphincterotomy with removal of ·Reprint requests: Timothy G, lee, MD, Department of Radiology, University of Oregon Health Sciences Center, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201. This work was supported in part by the George Alfred Cook Memorial Fund through the Medical Research Foundation of Oregon.
Figure 1. Tightly stenotic common bile duct at site of cho/edochoduodenostomy (arrow).
common duct stones endoscopically has been reported. a The positioning of an indwelling catheter at the time of endoscopy has been described. ' ° Recently, Burhenne 3 presented nonsurgical dilation of a common bile duct stricture through aT-tube To our knowledge, an attempt to dilate a common bile duct stricture endoscopically has not been reported. To share our initial experience is the purpose of this communication. CASE REPORT A 65-year-old woman with obstructive jaundice had a choledochoduodenostomy 23 years earlier. Endoscopic retrograde cholangiography demonstrated a tight stricture of the common bile duct (Figure 1). Using a 5 French Fogarty catheter outrigged to a front-viewing Olympus GIF-D panendoscope (Figure 2), the common bile duct was cannulated, and the inflated balloon was pulled through the stricture several times. At fluoroscopy, the Fogarty balloon was observed to deform as it passed through the stricture (Figure 3). Its compressibility did not allow it to achieve maximum dilatation. The patient experienced no discomfort or complication. At the time, a satisfactory balloon catheter was not available. The stricture was treated surgically 2 weeks later. DISCUSSION Strictures in the biliary ducts are not uncommon and may be associated with calculi, previous surgery, cholangitis, or pancreatitis. Sphincteroplasty or choledochoduodenostomy are often performed to correct the obstruction. Analysis of the surgical literature reveals that these procedures are often performed on elderly, poor risk patients who have had multiple previous biliary or pancreatic operations.',7,1l,15 Postoperative complications are
Figure 2. Fogarty balloon catheter outrigged to a forward viewing panendoscope.
Figure 3. Sequential films of Fogarty balloon passing through a strictured common bile duct: (a) proximal to stricture, (b) entering stricture, (c) deformed by stricture, and (d) distal to stricture. VOLUME 23, NO.3, 1977
171
frequent,·,12 and mortality averages 3%,7,12 Operation for recurrent stricture may be as high as 20%.'3'" Development of a nonoperative, repeatable approach to cholangiopancreatic ductal strictures would be of benefit in high risk patients. Even temporary relief of bi liary obstructions could be useful, as it might permit a period of medical management to improve the patient's condition in preparation for definitive surgery. If necessary, the dilation could be repeated. The efficacy of mechanical dilation of structures in the esophagus' and the experience of Burhenne 3 in dilating biliary strictures through a T-tube suggest that common duct strictures could be treated endoscopically. For our initial attempt, we were forced to outrig the catheter to the panendoscope, because the only Fogarty catheters available to us at the time were too short to pass through the biopsy channel. To avoid outrigging the endoscope, the length of such a catheter should be about 150 cm to 175 cm, which would be ample for use with the standard panendoscopes (working length, 100 cm) or duodenoscopes (working length, 120 cm). The Fogarty balloon proved to be too soft to achieve significant dilation, but a more rigid balloon catheter adaptable to the endoscope, if available, might have been more effective. While the risks of this procedure cannot be firmly estab~ Iished until a large number of cases have been studied, we experienced no difficulties in this first attempt. Furthermore, in the cases of therapeutic instrumentation reported by Burhenne,3 Nakajima et al.,8 and Shapiro and Cotton,'O no complications were reported. The complications of ERCP have been well documented. 2 We feel that endoscopic dilation of common bile duct strictures is feasible. Therapeutic applications ofthe fiberoptic endoscope are of increasing interest to endoscopists, and this paper is submitted to stimulate further investigation in this area. REFERENCES 1. BENSON CD, MUSTARD WT, RAVITCH MM, SNYDER WH, WELCH Kj: Pediatric Surgery. Chicago, Year Book Medical Publishers, 1962, pp. 286 and 293 2. BILBAO MK, DOTTER DT, LEE TG, KATON RM: Complications of endoscopic retrograde cholangiopancreatography (ERCP): Study of 10,000 cases. Gastroenterology 70:314, 1976 3. BURHENNE Hj: Dilatation of biliary tract strictures: a new roentgenologic technique. Radiologia Clin 44: 153, 1975 4. FARRAR T, PAINTER MW, BETZ ETZ R: Choledochoduodenostomy in the treatment of stenosis of the distal common bile duct. Arch Surg 98:442,
1969 5. KATON RM, LEE TG, PARENT jA, BILBAO MK, SMITH FW: Endoscopic retrograde cholangiopancreatography (ERCP): experience with 100 cases; Am I Dig Dis 19:295, 1974 6. McARTHUR MS, LONGMIRE WP jR: Peptic ulcer disease after choledochojejunostomy. Am I Surg 122:155, 1971 7. MADDEN jL, CHUN jY, KANDALAFT S, PAREKH M: Choledochoduodenostomy: an unjustly maligned procedure? Am I Surg 119:45, 1970 8. NAKAJIMA M, KIMOTO K, FUKUMOTO j, IKEHARA H, KAWAI K: Endoscopic sphincterotomy of the ampulla of Vater and removal of common duct stones. Am I Gastroenterol 64:34, 1975 9.01 I: Fiberduodenostomy and endoscopic pancreatocholangiography. Gastrointestinal Endoscopy 17:59, 1970 10. SHAPIRO HA, COTTON PB: Leaving a balloon-tip catheter in the bile duct at duodenoscopy: a new technique for sequential collection of pure bile in man. Lancet 2:13, 1975 11. STUART M, HOERR SO: Late results of side-to-side choledochoduodenostomy and of transduodenal sphincterotomy for benign disease. Am I Surg
123:67, 1972 12. THOMAS CG jR, NICHOLSON CP, OWEN j: Effectiveness of choledochoduodenostomy and transduodenal sphincterotomy in the treatment of benign obstruction of the common bile duct. Am Surg 173:845, 1971 13. WALTERS W, RAMSDELL jA: Study of 308 operations for stricture of the bile ducts. lAMA 171 :872, 1959 14. WALTMAN W (in discussion), SAWYER RB, SAWYER KC: Choledochoduodenostomy for gallstones. Arch Surg 102:308, 1971 15. WHITE TT: Indications for sphincteroplasty as opposed to choledochoduodenostomy. Am I Surg 126:165, 1973
172
Counsel to Authors
GASTROINTESTINAL ENDOSCOPY seeks to publish original papers describing investigations and significant observations relating to the various endoscopic techniques employed in the study of digestive diseases. Descriptions of new instruments or methods, innovative applications of endoscopy, analyses of experience, and extraordinary case reports are welcome subjects. Readers who are piqued or prodded by published articles are encouraged to submit brief comments that the editor may include in the "Reflex" section. Announcements of postgraduate courses, new fac iIities, cooperative stud ies, and other items of interest to endoscopists are invited. Address typescripts and editorial correspondence to the editor. Typescripts should be submitted in duplicate on white paper of standard (8'12 x 11 inches) si;e. All copy, including footnotes, references, and captions, should be double spaced with generous margins. The title page should include the author's name(s), the institution where the work was performed, and the name and address to which requests for reprints should be sent. Illustrations, including photographs and charts, should be submitted in duplicate as glossy prints, not less than 5 x 7 inches, preferably of uniform size. These must be unmounted and clearly labeled on the back, lightly in pencil, to indicate first author's name, figure number, and top of illustration. Radiographs and photographs must be of high contrast for proper reproduction. A reasonable number of pertinent illustrations in black and white can be allowed without charge. Top qual ity endoscopic photographs can be reproduced in color by special arrangement with the editor. References should be indicated by consecutive numbers in the text and enumerated at the end of the paper in the same order. Each reference should conform to the following example: Scope GE, Optic F: What we saw. Gastroenterology 500: 1001, 1962 All authors should be listed (not "et al."). Abbreviations of journal names are to be used as in Index Medicus. Helpful information pertaining to the preparation of scientific articles will be found in Style Manual for Biological Journals, Ed. 3, publ ished by American Institute of Biological Sciences, 3900 Wisconsin Ave., N.W., Washington, DC 20016. Galley proofs will be sent to the author for necessary corrections with the understanding that they are to be promptly returned. Reprints should be ordered when galley proofs are returned. A purchase form will be furnished. Authors are reminded to retain in their own files a copy of the typescript and illustrations submitted.
GASTROINTESTINAL ENDOSCOPY
