John

R. Mathieson,

MD

#{149}

Dashefsky,

MD3

#{149}

Sidney

Peter Ralph

Pancreatic

with ofa

Duct

struction pancreatitis. derwent

months, sertion

larger

use of metal stents to treat pancreatic duct obstruction has not been reported.

chronic initially unexternal pancrethen had metal

patients and

for

Percutaneous which can

diameter.

We report causing

duct

obstruction

cessfully insertion

after a trial of external drainage has been shown to relieve the patient’s symptoms, should be considered as an alternative to endoscopic stent placement or surgical drainage.

terms:

as,

radiography,

Pancreas,

CT,

770.121

procedure, 774.1299

774.1299,

774.921

Radiology

1992;

1

PancrePancreducts,

#{149}

774.1299

#{149}

Pancreatic 770.291

#{149}

#{149} Pancreatitis,

185:465-467

duct

ANCREATIC

obstruction

has cus-

the distal part of the pancreas (1,2). More recently, plastic stents have been inserted in a retrograde fashion by enfor treatment of a variety of ductab abnormalities, includobstruction (3,4).

Expanding

metal

stents

have

been

used

in the treatment of vascular biliary obstruction as an alternate

standard

plastic

posed

that

catheters

metal

longer relief tic catheters,

and to

(5-8).

stents

might

of obstruction due to their

give

than do plasconsiderably

From

P.L.C.,

the

Departments

of Radiology

(J.R.M.,

D.J.M., S.D., N.S.) and Surgery

University

tab, 1081

of British

Burrard

Columbia,

St. Vancouver,

V6Z 1Y6. Received requested February 22; accepted June

January

(R.C.),

St Paul’s

Hospi-

BC, Canada

16, 1992; revision

17; revision 22. Address

received

reprint

May

requests

to J.R.M. 2 Current address: ter, Spokane, Wash. 3 Current address: Winnipeg, Manitoba,

C

RSNA,

1992

Sacred

Heart

Health Sciences Canada.

Medical Centre,

Cen-

Case

pancre-

was

sue-

REPORTS woman

with

nations

showed

ductal

dilatation,

biliary

a

measuring

onset of jaun(US) examiand

with

pancreatic

the pancreatic

10 mm

in

diameter.

remained

decom-

81-year-old

seen

in 1986

jaundice.

white

with

man

painful

ob-

An abdominal

US

scan showed a 5-cm pancreatic mass and dilated bile ducts. Percutaneous biopsy showed no malignant cells. A cholecystojejunostomy was performed, and an open intraoperative biopsy showed inflammatory changes with no

antegrade

57-year-old

duct

2.-An

first

structive

treated

inab pain and had recent dice. Sequential ultrasound

A

tomographic (CT) scan showed a dilated pancreatic duct and several small pseudocysts in the head of the pancreas, but no evidence of a neo-

malignant cells. well for 4 years, seen

with

The patient remained when he again was

painful

obstructive

jaundice.

Abdominal US again showed a 5-cm pancreatic mass, dilated bile ducts, and a pancreatic fluid collection (Fig 6). Percutaneous biopsy of the mass was again negative for malignancy. Percutaneous

computed

transhepatic

plasm

iary drainage were performed, and Cianturco-ROsch metal stents were inserted. The pancreatic fluid collection was aspirated, and contrast medium was injected. Since clear serous fluid was obtained and Gram stains and cubtures were negative, a catheter was not

(Fig

1). Endoscopic

due

to

pancreatic

retrograde

First,

was unsuc-

inability

to

cannulate

the

duct.

percutaneous

pancreatic

duct

drainage

was

pigtail catheter bated pancreatic guidance and

of the

performed.

An 8-F

was placed in the diduct by means of US the Seldinger technique

(Fig 2). Next, percutaneous biliary drainage allowed identification of a short stricture of the distal common bile

duct. Multiple brush biopsies showed no malignant cells. Since the drainage procedure produced relief of the patient’s chronic abdominal

It is pro-

her pancreatic pressed.

history of alcohol abuse and chronic pancreatitis reported worsening abdom-

pain

24 hours,

within

it was

decided to attempt placement of a metal stent for internal pancreatic drainage. A guide wire and catheter were manipulated through the pancreatic duct stricture into the duodenum, the stricture was

I

was

cholangiopancreatography

tomarily been treated with surgery, either by creating an anastomosis between the obstructed pancreatic duct and a loop of jejunum or by resecting

doscopists pancreatic ing duct

-A

the

pancreatic

that

CASE

cessful

P

of chronic

with percutaneous of a metal stent.

Case 1

duct

interventional

knowledge,

symptomatic

in-

struction

Index

two cases

atitis

be

duct ob-

To our

Insertion Cases’

to

to treat pancreatic

as,

Treated

ob-

respectively. of metal stents,

performed

MD

duct

drainage

inserted

Schmidt,

Antegrade Report ofTwo

internal drainage. Both patients remained asymptomatic, and the stents were patent during short-term follow-up periods of 6 and 9 stents

Nis

#{149}

used

percutaneous

atic duct

MD

MD2

Murray,

were

stents

in two Both

Christensen,

J.

Daniel

#{149}

pancreatic patients with

metal

symptomatic

MD

Obstruction

Percutaneous Metal Stent:

Expanding

treat

L. Cooperberg,

dilated

with

an

8-mm

balloon

catheter

lapping

Gianturco-R#{246}sch

cm) metal

stents

(Cook,

Ind)

placed

across

were

angiographic

(Fig 3), and

two

(8 mm

overx 3.0

Bloomington, the

obstruction.

The biliary stricture was treated by inserting two overlapping GianturcoROsch metal stents (10 mm x 3.0 cm) (Figs

4, 5).

The patient was discharged from the hospital the following day. She has remained free of abdominal pain for 9 months,

and

repeated

US showed

that

cholangiography

and

bib-

inserted into the pancreatic collection. The symptoms of obstructive jaundice resolved quickly. Two months later, the patient presented with leukocytosis.

fever, abdominal pain, US showed echogenic

terial

within

the pancreatic

tion,

and

percutaneous

fluid

and ma-

collec-

aspiration

per-

formed with US guidance revealed pus. An 8-F catheter was then inserted into the pancreatic fluid collection for drainage.

The

sepsis

cleared

within

a week,

but a continuous output of clear fluid (40-100 mL per day) containing high amylase

levels

was

noted.

A contrast

pancreatogram showed that this was not a pseudocyst but was a markedly dilated pancreatic duct (Fig 7). A guide wire and catheter were then manipubated through the duct and into the duodenum with fluoroscopic guidance. The pancreatic duct stricture was then dilated with an 8-mm angiographic babloon (Fig 8), and three overlapping Gianturco-R#{246}sch metal stents (8 mm x 3.0 cm) were inserted. A safety catheter was left in the duct for 24 hours and was removed after injection of contrast medium helped confirm stent patency (Fig 9).

The

being

patient’s

able

pain

resolved

to eat without

pain,

quickly;

he

4c

1.

2.

4.

3.

Figures

1-5. Case

trahepatic

bile

plete

1.

ducts.

obstruction

(1) CT scan (2) Spot

and

several

atic duct. Note patency of the

the biliary pancreatic

atic

metal

and

biliary

gained

weight,

shows radiograph

small

a dilated shows

communicating

progressively

duct

remained

Both

patients

were

an experimental

informed procedure,

that

this

and

that the safety and efficacy of this treatment were unknown. Both patients were also informed of alternate treatment options, and written informed consent

was

cess

466

can

#{149} Radiology

external

catheter

performed

drainage

because

pancreatic

be successfully

have are

catheter

dilating safety

shows

and mildly dilated induct, showing com-

the stricture of the pancrecatheter demonstrates

good

position

is usually

major

duct treated

or with par(1,2). Although a satisfactory surgical

sueproce-

et ab (4) performed ment of pancreatic not

of the risk of deveb-

a permanent

cutaneous

fistuba.

In

recent years, endoscopists have attempted to treat abnormalities of the pancreatic duct by means of balloon dilation (9-11) and retrograde insertion of plastic

stents

into

McCarthy scopic

the

pancreatic

duct.

et al (3) performed

stent

placement

endo-

across

the

major

visum

chronic

they

safety

DISCUSSION

operations rate,

a bibiary

or minor papilla in 35 patients. Seventeen of 22 patients with pancreas di-

with pancreatojejunostomy tial pancreatic resection these

shows a balloon catheter medium through a pancreatic

obtained.

Symptomatic, obstruction

(3) Radiograph

dures that are associated with significant morbidity and mortality. Simple

oping

decom-

pressed. was

pseudocysts.

in the head of the pancreas, medium outlines the dilated

of both

the

pancre-

stents.

became

pancreatic

duct, three small pseudocysts in the pancreatic duct. Contrast

drainage catheter in place. (4) Injection of contrast metal stents. (5) Contrast medium injection through

mobilized, and was discharged home from the hospital. He was free of pain at 6 months, and repeated US showed that his

5.

pancreatic a catheter

rent

and

14 of 15 patients

pancreatitis

tients lated

recur-

underwent successful Eight of the latter 14

stent placement. patients had improvement

placement,

with

including

with

four

with pancreatic duct to alcoholic pancreatitis.

stent

of five pastricture reKozarek

tients,

eight

endoscopic duct stents

of whom

had

placein 17 pa-

duct

obstruc-

tion related to chronic pancreatitis. Six of these patients had bong-term relief of symptoms, and two had short-term symptomatic relief before surgical treatment. Although patients have

with

only small numbers undergone treatment

endoscopically

creatic

duct

stents,

placed the

initial

plastic

of

pan-

results

have been favorable. It seems reasonable to pursue alternate forms of therapy

for

pancreatic

are less invasive

duct

than

obstruction

open

that

surgical

pro-

have

been

cedures.

A wide

variety

of materials

used for making stents, but years several different metal theses have been developed.

turco-R#{246}sch stent

and

in recent endoprosThe Gian-

the Walbstent November

1992

term

treatment

for pancreatic

duct

ob-

struction. We suggest that endoscopic stent placement be regarded as the miflab treatment of choice in such patients. Indeed,

endoscopic

placement

of metal

stents may be used to treat pancreatic duct obstruction in the near future. We

believe

it is important

to reserve

percutaneous metal stent placement for those cases of pancreatic duct obstruction in which it is clearly demonstrated to be of clinical value, and tempted endoscopic stent

6.

in which placement

has been unsuccessful. Therefore, recommend initial placement of ternal drainage catheter into the creatic duct, with progression to nab stent placement only in cases which the first procedure provides

7.

symptomatic

at-

we an expaninterin

#{149}

relief.

References 1.

Bradley

2.

atojejunostomy in patients with chronic pancreatitis. AmJ Surg 1987; 153:207-213. Greenlee HB, Prinz RA, Aranha GV. Long-term results of side-to-side pancreatojejunostomy. World J Surg 1990; 14:70-

EL.

Long-term

results

of pancre-

76.

3.

4.

Figures

6-9.

Case

2.

(6) Transverse

abdominal

collection. (7) Spot radiograph shows contrast catheter, demonstrating complete obstruction

US scan

shows

a safety

catheter

and

passing

through

pancreatic

5.

fluid

pancreatic

being used to dilate the stricture duct distally. Metal stents are contrast medium injected metal

stents

into

the

6.

duodenum.

7.

(Schneider, Lausanne, Switzerland) are the most commonly used metal stents. Both are made of stainless steel but differ in the

size

of metal

mesh

used,

with

the Wabbstent employing a much finer mesh and smaller-gauge wire. Neither stent, however, is intended as an impenetrable barrier; each simply serves to open strictures to a larger diameter. We use the Gianturco-ROsch stent rather than the Wallstent because of the considerable difference in price. It has been proposed that metal stents might remain patent longer than do plastic stents, mainly because of an approximately threefold increase in internal diameter. It has been shown that endothelial overgrowth occurs rapidly, possibly reducing or eliminating the

‘Tol’me

185

#{149} Number

2

problems

associated

(5).

are

There

open

with spaces

foreign between

bodies

stents

can

be successfully

inserted

8.

the

metal struts, however, and tissue ingrowth is not prevented. Since metal stents cannot be removed, eventual blockage might be considered a serious problem. Nevertheless, it has been shown that blockage of metal stents in bile ducts can be treated with subsequent insertion of plastic stents through the blocked metal stents (7). Our two cases demonstrate that metal

WJ.

Pre-

endoscopic

stent

placement in benign pancreatic diseases. Gastrointest Endosc 1988; 34:16-18. Kozarek RA, Patterson DJ, Ball TJ, Traverso LW. Endoscopic placement of pancreatic

Wright

drains Ann

KC,

in the management Surg 1989; 209:261-266.

Wallace

of

5, Charsangavej

C,

Carrasco CH, al. Expandable

Wallace S. Charsangavej biliary endoprosthesis:

experimental

study.

in progress.

9.

SiegelJH, Guelrud langiopancreatoplasty:

M.

Guelrud

choballoon

1983;

as a cause

K, Hagenmu!!er balloon duct

Gastroenterol Jackson JE,

1985; Roddie

IS, Adam

29:99-103.

Hypertensive

pan-

of pancre-

treatment with hydrostatic Dig Dis Sci 1984; 29:225-

Endoscopic the pancreatic

jamin

Work

177:789-792.

Endoscopic hydrostatic

M.

duct sphincter

atitis: successful balloon dilatation.

231. Knyrim

drainage.

1990;

Endosc

SiegelJH,

creatic

12.

145:1279-

in the bile duct and pancreas.

Gastrointest

11.

1985;

for biliary Radiology

dilatation 10.

AJR

C, et

1281. Coons H. Self-expanding stainless steel biliary stents. Radiology 1989; 170:979-983. LammerJ, Klein GE, Kleinert R, et al. Obstructive jaundice: use of expandable metal

endoprosthesis

with

an antegrade percutaneous approach to treat pancreatic duct strictures, and can provide relief of ductal obstruction for many months. Our experience involves only two patients with limited followup, and we do not know whether this can be regarded as an effective long-

with

Carrasco CH, Gianturco C. Percutaneous endovascular stents: experimental evaluation. Radiology 1985; 156:69-72.

medium injected through a pancreatic drainage of the duct. Metal stents are present in the com-

mon bile duct. (8) Spot radiograph shows a balloon catheter of the pancreatic duct. Note contrast medium in the dilated present in the common bile duct. (9) Spot radiograph shows through

a 7 x 4-cm

JE, Hogan

experience

stents and pancreatitis.

9.

8.

I, Geenen

McCarthy liminary

A.

F, C!assen

M.

dilatation in stenosis orifice (case report). 23:74-78. ME,

The

Chetty

N,

management

of Z

Ben-

of

occluded metallic self-expandable biliary endoprostheses. AJR 1991; 157:291-292.

Ruinlnv

#{149} 4(;7