Cardiovasc Intervent Radiol (1992) 15:256-260
Card,Vascular andInterventional 9 Springer-Ver[ag New York Inc. 1992
Percutaneous Hepaticoneojejunostomy and Choledochocholedochal Reanastomosis Using Metallic Stents: Technical Note K r a s s i I v a n c e v , 1"3 B r y a n P e t e r s e n , ~ L e e H a l l ] Paul H o , ) K e n t B e n n e r , 2 a n d J o s e f R 6 s c h 1 ~Charles Dotter Institute of Interventional Therapy, :Department of Gastroenterology, Oregon Health Sciences University, Portland, Oregon USA; and 3Department of Diagnostic Radiology, University of Lund, Malmo General Hospital, Malmo, Sweden
A b s t r a c t . A n e w , n o n s u r g i c a l a p p r o a c h to biliary d u c t r e c o n s t r u c t i o n in t w o h i g h - o p e r a t i v e risk pat i e n t s is p r e s e n t e d . T h e first p a t i e n t with an obs t r u c t e d h e p a t i c o j e j u n o s t o m y u n d e r w e n t s u c h reconstruction by placement of Wallstent, which r e m a i n e d p a t e n t 9 m o n t h s until d e a t h f r o m rec u r r e n t t u m o r , T h e s e c o n d p a t i e n t with an inadv e r t e n t l y l i g a t e d c o m m o n bile d u c t u n d e r w e n t a c o m b i n e d p e r c u t a n e o u s t r a n s h e p a t i c - r e t r o g r a d e en d o s c o p i c r e c o n s t r u c t i o n w i t h p l a c e m e n t o f a Gia n t u r c o - R 6 s c h (GR) stent. B e c a u s e of occlusion by g r a n u l a t i o n t i s s u e 5 m o n t h s l a t e r , a n e w G R stent c o v e r e d with a silicone m e m b r a n e was placed w i t h i n t h e initial s t e n t . N i n e m o n t h s a f t e r the s e c o n d G R s t e n t p l a c e m e n t t h e r e is no e v i d e n c e of obstruction. K e y w o r d s : Bile d u c t o c c l u s i o n - - P e r c u t a n e o u s construction--Metallic stents
re-
T h e t r e a t m e n t o f c h o i c e f o r b e n i g n bile d u c t o c c l u sions h as b e e n s u r g i c a l w i t h little o r n o a l t e r n a t i v e . H o w e v e r , bile d u c t s u r g e r y in p a t i e n t s w h o h ad u n d e r g o n e p r e v i o u s o p e r a t i o n s is a s s o c i a t e d w i t h i n c r e a s e d m o r b i d i t y a n d m o r t a l i t y [1]. In a d d i t i o n , the r e c u r r e n c e r a t e is h i g h e r f o r e a c h a t t e m p t e d s u r g i c a l r e p a i r o f b e n i g n bile d u c t s t r i c t u r e s [1, 2]. We describe a nonsurgical, percutaneous reconstruction of postoperatively occluded, extrahepatic bile d u c t s in 2 p a t i e n t s at high o p e r a t i v e risk uti l i zi n g i n t e r v e n t i o n a l t e c h n i q u e s a n d e x p a n d a b l e metallic stents.
Address reprint requests to." Krassi Ivancev, M.D., Department of Diagnostic Radiology, University of Lund, Maim6 General Hospital, S-214 01 Malmo, Sweden
Case Reports Case l A 66-year-old white male presented with symptoms of biliary obstruction 3 months after a Whipple procedure for ampullary carcinoma. Percutaneous transhepatic cholangiography (PTC) revealed total obstruction of the hepaticojejunostomy with moderately dilated intrahepatic ducts (Fig. IA). When initial attempts at crossing the obstruction were unsuccessful, external transhepatic drainage was established. Surgical revision was not performed because the patient was considered to be a high operative risk. The patient did not accept permanent external drainage and opted for the proposed percutaneous reconstruction of the biliary passage. Ten days later the tract was dilated to 10F. The reconstruction procedure was performed with the patient under mild sedation. A 19-gauge, 22 cm long, gently curved needle inside a 5F sheath (PTC needle, Surgimed A/S, Denmark) was used to puncture the obstructed duct. The needle was introduced coaxially through a 10F introducer sheath to the bottom of the occluded hepatic duct. Directed at the nearest air-distended loop of jejunum, approximately 5 mm from the occluded duct, the needle was advanced under biplane fluoroscopic visualization. After five attempts, the jejunal loop was entered and the position of the needle was verified with injection of contrast medium (Fig. 1B). The 5F sheath was then advanced into the jujunal loop over a 0,035 inch guidewire and the newly established biliary-jejunal anastomosis was sequentially dilated to 9F followed by 10 mm balloon dilation, There was no evidence of external bleeding or extravasation of contrast medium. An expandable metallic stent, Wallstent (Medinvent, Switzerland) 4 cm long and 1 cm in diameter was then placed across the hepaticoneojejunostomy (Fig. IC). Nearly full stent expansion was achieved following its dilation with a 10 mm balloon catheter. External drainage was continued for 1 more day and then removed after adequate internal biliary passage was confirmed b...'!.,,;. " :i,~.::. :"". "Fi,. 'D" The patient improved ...'..'.c. 9 9 .. . . . . . ';' c :", ,'..,. ,:' .. and his jaundice receded. However, he started to complain of severe upper abdominal pain, the etiology of which could not be found in spite of multiple diagnostic studies, including several negative computed tomography/CT) scans. Three months after the biliary reconstruction he underwent an exploratory laparotomy which was unrevealing except that the stent, having fully opened, was considered by the surgeon to be a potential source of pain, and was shortened by 2 cm at the jejunal end. The pain, however, did not subside following the operation and the patient started to deteriorate. He died 9 months after the reconstruction of tumor recurrence and widespread metastases. He remained anicteric until his death.
K. l,,ancev et al. Percutaneous Hepattconeojejunostomy
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Fig, 1, A PTC demonstrating moderate biliary duct dilatation and complete occlusion at the level of the hepaticojejunostomy. B Puncture with l%gauge needle through the obstructed common hepatic duct (CHD) establishing continuity between CHD and the jejunum. C Wallstent placed across percutaneously created hepaticoneojejunostomy. D Free flow through stented hepaticoneojejunostomy w~thout extravasation.
Case 2 A 41-year-old white male with idtopathlc cavernous transfortion of the portal veto underwent two portosybtemic shunt
'..~. . 's
'" .
procedures because of recurrent vanceal bleeding. The first procedure, a spleno-renal shunt, thrombosed and was followed by a meso-caval shunt which remained patent. The second surgery was complicated by inadvertent ligation of the common bile duct (CBD) which was treated by cholecystolejunostomy. The patmnt presented 2 years later with obstructive cholang~tis. A PTC revealed diffusely enlarged bile ducts and multiple 1-2.5 cm large stones m the proximal CBD segment, in right and left hepatic ducts and m the cystic duct ~Fig. 2A). The cholecystojejunostomy was narrowed and showed slow drainage. The transhepatic tract was dilated to 12F. Mechamcal lithotripsy was then performed w~th Dormm baskets on two occasions, removing all but a large 2 5 cm stone m the proximal CBD segment.
258
K. Ivancev et al.: Percutaneous Hepaticoneojejunostomy
2
,,,-~
,,
,
-=
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Fig. 2. A PTC demon,~trating multiple bile duct stones and CBD occlusion. B Following lithotripsy, the bile ducts are stone free. Note narrow cholecystojejunostomy {arrowhead J.
This stone was fragmented by extracorporeal shock wave hthotripsy (Dornier HM-3. 2000 shocks) and the residual debris was evacuated (Fig. 2B). The distance between the ligated CBD segments measured less than 10 mm by comparing the present PTC and the endoscopic retrograde cholang~ogram (ERC) performed at the time of cholecystojejunostomy; therefore, percutaneous bdiary neoanastomosis was offered to the patient. This was considered a less risky treatment option than surgery, in the face of extensive postsurgzcal adhesions and venous collaterals in the hepatic hilum. The procedure was done under general anesthesia in cooperation with gastroenterology. The distal CBD segment was first opac~fied by a balloon catheter placed endoscopically (Fig. 3A). A 12F catheter was then introduced percutaneously and advanced to stretch the occluded proximal CBD segment and bring it closer to the distal CBD segment. Under biplane fluoroscopy, a sharpened gmdewire {Hawkins-Hunter "'rocket" wire. Cook Inc., Bloomington, IN) was introduced for puncture of the obstructed duct. It proved unsuccessful because the firm obstruction deflected the "'rocket" wire. in addition, it was difficult to visualize the rocket wire because of its low radiopacity, The puncture was subsequently performed with a 25 cmlong fiextble 2l gauge biopsy needle (Surgimed A/S, Denmark) introduced through a 4F catheter. Puncture was made against significant resistance and succeeded at the third attempt A 0,016 inch platinum tip wire tTarget, Inc, San Jose, CA) was then passed through the needle into the distal CBD and into the duodenum (Fig. 3B)9 The puncture tract was progressively dilated and an 8F catheter was placed with its tip in the duodenum for internal drainage. There was minimal extravasation of contrast medium from the proximal CBD portton as well as negligible bleeding following the punctures {Fig. 3B). Six weeks later the newly established CBD anastomosis was dilated to 12F and further dilated with a 10 mm balloon under
general anesthesia, Reconstruction was then completed by placement of a triple-bodied 4,5 cm long, 10 mm diameter, GianturcoR6sch (GR) expandable stent (Cook Inc.) across the previously ligated segment. The drainage catheter was removed 2 days later after confirming patency of the stent by cholangiography (Fig. 3C). Five months after stent placement the patient remained asymptomatic. However, elevated liver function tests, suggesting partial obstruction, prompted hepatobiliary scintigraphy (HIDA) and ERC which demonstrated preferential flow through the chotecystojejunostomy and occlusion at the tevel of the stented CBD. Repeat PTC under general anesthesia confirmed the obstruction {Fig. 4Al which was crossed. Following percutaneous placement of a 14F sheath, a 7F choledochoscope and a 7F Simpson atherectomy catheter {DVI, Inc, Redwood City, CA) were used to identify and biopsy the obstruction found to be caused by granulation tissue protruding through the struts of the stem at the level of the previous CBD hgation. One week later9 under general anesthesm, repeat biopsy and excision of the protruding granulation tissue was performed with a 9F Simpson atherectomy catheter. The tract was again preditated to 10 mm with a balloon catheter. A 3 cm long, l0 mm diameter GR stent covered with a silicone membrane was then placed within the original stent to prevent further ingrowth of granulation tissue. An endoscopic sphincterotomy was also performed. A 5F catheter left above the stented CBD was used to confirm patency of the stent by chotangiography 1 month later (Fig. 4B). The catheter was then removed. Oral therapy with ursodeoxychotic acid was initiated and the patient has been working full time since. Liver function tests remain unremarkable 9 months after placement of the second stent. A HIDA scan 5 months after the second stent placement demonstrated prompt flow to the duodenum w~th no flow through the cholecystojejunostomy,
K, |vancev et at.: Percutaneous Hepaticoneojeiunostomy
259
Fig. 3. A Combined ERC and PTC ~lateral viewL showing the proximity (
Card,Vascular andInterventional 9 Springer-Ver[ag New York Inc. 1992
Percutaneous Hepaticoneojejunostomy and Choledochocholedochal Reanastomosis Using Metallic Stents: Technical Note K r a s s i I v a n c e v , 1"3 B r y a n P e t e r s e n , ~ L e e H a l l ] Paul H o , ) K e n t B e n n e r , 2 a n d J o s e f R 6 s c h 1 ~Charles Dotter Institute of Interventional Therapy, :Department of Gastroenterology, Oregon Health Sciences University, Portland, Oregon USA; and 3Department of Diagnostic Radiology, University of Lund, Malmo General Hospital, Malmo, Sweden
A b s t r a c t . A n e w , n o n s u r g i c a l a p p r o a c h to biliary d u c t r e c o n s t r u c t i o n in t w o h i g h - o p e r a t i v e risk pat i e n t s is p r e s e n t e d . T h e first p a t i e n t with an obs t r u c t e d h e p a t i c o j e j u n o s t o m y u n d e r w e n t s u c h reconstruction by placement of Wallstent, which r e m a i n e d p a t e n t 9 m o n t h s until d e a t h f r o m rec u r r e n t t u m o r , T h e s e c o n d p a t i e n t with an inadv e r t e n t l y l i g a t e d c o m m o n bile d u c t u n d e r w e n t a c o m b i n e d p e r c u t a n e o u s t r a n s h e p a t i c - r e t r o g r a d e en d o s c o p i c r e c o n s t r u c t i o n w i t h p l a c e m e n t o f a Gia n t u r c o - R 6 s c h (GR) stent. B e c a u s e of occlusion by g r a n u l a t i o n t i s s u e 5 m o n t h s l a t e r , a n e w G R stent c o v e r e d with a silicone m e m b r a n e was placed w i t h i n t h e initial s t e n t . N i n e m o n t h s a f t e r the s e c o n d G R s t e n t p l a c e m e n t t h e r e is no e v i d e n c e of obstruction. K e y w o r d s : Bile d u c t o c c l u s i o n - - P e r c u t a n e o u s construction--Metallic stents
re-
T h e t r e a t m e n t o f c h o i c e f o r b e n i g n bile d u c t o c c l u sions h as b e e n s u r g i c a l w i t h little o r n o a l t e r n a t i v e . H o w e v e r , bile d u c t s u r g e r y in p a t i e n t s w h o h ad u n d e r g o n e p r e v i o u s o p e r a t i o n s is a s s o c i a t e d w i t h i n c r e a s e d m o r b i d i t y a n d m o r t a l i t y [1]. In a d d i t i o n , the r e c u r r e n c e r a t e is h i g h e r f o r e a c h a t t e m p t e d s u r g i c a l r e p a i r o f b e n i g n bile d u c t s t r i c t u r e s [1, 2]. We describe a nonsurgical, percutaneous reconstruction of postoperatively occluded, extrahepatic bile d u c t s in 2 p a t i e n t s at high o p e r a t i v e risk uti l i zi n g i n t e r v e n t i o n a l t e c h n i q u e s a n d e x p a n d a b l e metallic stents.
Address reprint requests to." Krassi Ivancev, M.D., Department of Diagnostic Radiology, University of Lund, Maim6 General Hospital, S-214 01 Malmo, Sweden
Case Reports Case l A 66-year-old white male presented with symptoms of biliary obstruction 3 months after a Whipple procedure for ampullary carcinoma. Percutaneous transhepatic cholangiography (PTC) revealed total obstruction of the hepaticojejunostomy with moderately dilated intrahepatic ducts (Fig. IA). When initial attempts at crossing the obstruction were unsuccessful, external transhepatic drainage was established. Surgical revision was not performed because the patient was considered to be a high operative risk. The patient did not accept permanent external drainage and opted for the proposed percutaneous reconstruction of the biliary passage. Ten days later the tract was dilated to 10F. The reconstruction procedure was performed with the patient under mild sedation. A 19-gauge, 22 cm long, gently curved needle inside a 5F sheath (PTC needle, Surgimed A/S, Denmark) was used to puncture the obstructed duct. The needle was introduced coaxially through a 10F introducer sheath to the bottom of the occluded hepatic duct. Directed at the nearest air-distended loop of jejunum, approximately 5 mm from the occluded duct, the needle was advanced under biplane fluoroscopic visualization. After five attempts, the jejunal loop was entered and the position of the needle was verified with injection of contrast medium (Fig. 1B). The 5F sheath was then advanced into the jujunal loop over a 0,035 inch guidewire and the newly established biliary-jejunal anastomosis was sequentially dilated to 9F followed by 10 mm balloon dilation, There was no evidence of external bleeding or extravasation of contrast medium. An expandable metallic stent, Wallstent (Medinvent, Switzerland) 4 cm long and 1 cm in diameter was then placed across the hepaticoneojejunostomy (Fig. IC). Nearly full stent expansion was achieved following its dilation with a 10 mm balloon catheter. External drainage was continued for 1 more day and then removed after adequate internal biliary passage was confirmed b...'!.,,;. " :i,~.::. :"". "Fi,. 'D" The patient improved ...'..'.c. 9 9 .. . . . . . ';' c :", ,'..,. ,:' .. and his jaundice receded. However, he started to complain of severe upper abdominal pain, the etiology of which could not be found in spite of multiple diagnostic studies, including several negative computed tomography/CT) scans. Three months after the biliary reconstruction he underwent an exploratory laparotomy which was unrevealing except that the stent, having fully opened, was considered by the surgeon to be a potential source of pain, and was shortened by 2 cm at the jejunal end. The pain, however, did not subside following the operation and the patient started to deteriorate. He died 9 months after the reconstruction of tumor recurrence and widespread metastases. He remained anicteric until his death.
K. l,,ancev et al. Percutaneous Hepattconeojejunostomy
....
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. .,.:.~,,
,
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,~'-~,:',."-:[.~'*" ~;
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,..
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9 i ~
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~. . . .
257
:
.
. ".
..' "4 'g'-
~g"",:" ; , . . ,.('-",' 9.:
9 ",.'t~i,.'
ve
~ "
Fig, 1, A PTC demonstrating moderate biliary duct dilatation and complete occlusion at the level of the hepaticojejunostomy. B Puncture with l%gauge needle through the obstructed common hepatic duct (CHD) establishing continuity between CHD and the jejunum. C Wallstent placed across percutaneously created hepaticoneojejunostomy. D Free flow through stented hepaticoneojejunostomy w~thout extravasation.
Case 2 A 41-year-old white male with idtopathlc cavernous transfortion of the portal veto underwent two portosybtemic shunt
'..~. . 's
'" .
procedures because of recurrent vanceal bleeding. The first procedure, a spleno-renal shunt, thrombosed and was followed by a meso-caval shunt which remained patent. The second surgery was complicated by inadvertent ligation of the common bile duct (CBD) which was treated by cholecystolejunostomy. The patmnt presented 2 years later with obstructive cholang~tis. A PTC revealed diffusely enlarged bile ducts and multiple 1-2.5 cm large stones m the proximal CBD segment, in right and left hepatic ducts and m the cystic duct ~Fig. 2A). The cholecystojejunostomy was narrowed and showed slow drainage. The transhepatic tract was dilated to 12F. Mechamcal lithotripsy was then performed w~th Dormm baskets on two occasions, removing all but a large 2 5 cm stone m the proximal CBD segment.
258
K. Ivancev et al.: Percutaneous Hepaticoneojejunostomy
2
,,,-~
,,
,
-=
=,
Fig. 2. A PTC demon,~trating multiple bile duct stones and CBD occlusion. B Following lithotripsy, the bile ducts are stone free. Note narrow cholecystojejunostomy {arrowhead J.
This stone was fragmented by extracorporeal shock wave hthotripsy (Dornier HM-3. 2000 shocks) and the residual debris was evacuated (Fig. 2B). The distance between the ligated CBD segments measured less than 10 mm by comparing the present PTC and the endoscopic retrograde cholang~ogram (ERC) performed at the time of cholecystojejunostomy; therefore, percutaneous bdiary neoanastomosis was offered to the patient. This was considered a less risky treatment option than surgery, in the face of extensive postsurgzcal adhesions and venous collaterals in the hepatic hilum. The procedure was done under general anesthesia in cooperation with gastroenterology. The distal CBD segment was first opac~fied by a balloon catheter placed endoscopically (Fig. 3A). A 12F catheter was then introduced percutaneously and advanced to stretch the occluded proximal CBD segment and bring it closer to the distal CBD segment. Under biplane fluoroscopy, a sharpened gmdewire {Hawkins-Hunter "'rocket" wire. Cook Inc., Bloomington, IN) was introduced for puncture of the obstructed duct. It proved unsuccessful because the firm obstruction deflected the "'rocket" wire. in addition, it was difficult to visualize the rocket wire because of its low radiopacity, The puncture was subsequently performed with a 25 cmlong fiextble 2l gauge biopsy needle (Surgimed A/S, Denmark) introduced through a 4F catheter. Puncture was made against significant resistance and succeeded at the third attempt A 0,016 inch platinum tip wire tTarget, Inc, San Jose, CA) was then passed through the needle into the distal CBD and into the duodenum (Fig. 3B)9 The puncture tract was progressively dilated and an 8F catheter was placed with its tip in the duodenum for internal drainage. There was minimal extravasation of contrast medium from the proximal CBD portton as well as negligible bleeding following the punctures {Fig. 3B). Six weeks later the newly established CBD anastomosis was dilated to 12F and further dilated with a 10 mm balloon under
general anesthesia, Reconstruction was then completed by placement of a triple-bodied 4,5 cm long, 10 mm diameter, GianturcoR6sch (GR) expandable stent (Cook Inc.) across the previously ligated segment. The drainage catheter was removed 2 days later after confirming patency of the stent by cholangiography (Fig. 3C). Five months after stent placement the patient remained asymptomatic. However, elevated liver function tests, suggesting partial obstruction, prompted hepatobiliary scintigraphy (HIDA) and ERC which demonstrated preferential flow through the chotecystojejunostomy and occlusion at the tevel of the stented CBD. Repeat PTC under general anesthesia confirmed the obstruction {Fig. 4Al which was crossed. Following percutaneous placement of a 14F sheath, a 7F choledochoscope and a 7F Simpson atherectomy catheter {DVI, Inc, Redwood City, CA) were used to identify and biopsy the obstruction found to be caused by granulation tissue protruding through the struts of the stem at the level of the previous CBD hgation. One week later9 under general anesthesm, repeat biopsy and excision of the protruding granulation tissue was performed with a 9F Simpson atherectomy catheter. The tract was again preditated to 10 mm with a balloon catheter. A 3 cm long, l0 mm diameter GR stent covered with a silicone membrane was then placed within the original stent to prevent further ingrowth of granulation tissue. An endoscopic sphincterotomy was also performed. A 5F catheter left above the stented CBD was used to confirm patency of the stent by chotangiography 1 month later (Fig. 4B). The catheter was then removed. Oral therapy with ursodeoxychotic acid was initiated and the patient has been working full time since. Liver function tests remain unremarkable 9 months after placement of the second stent. A HIDA scan 5 months after the second stent placement demonstrated prompt flow to the duodenum w~th no flow through the cholecystojejunostomy,
K, |vancev et at.: Percutaneous Hepaticoneojeiunostomy
259
Fig. 3. A Combined ERC and PTC ~lateral viewL showing the proximity (
