Surg Endosc (1992) 6:36-37
Surgical Endoscopy © Springer-VerlagNew York Inc. 1992
Peroral enteroscopic removal of a retained percutaneous transhepatic guidewire from the jejunum using a colonoscope Donald N. Reed, Jr. 1, Joseph C. Young l, Ricardo J. Mitre 2, and Robert Pagano 2 Divisions of ~General Surgery and 2 Gastroenterology, Allegheny General Hospital, Pittsburgh, PA 15212, USA
Summary. Several authors have described the ability to perform small-intestine endoscopy with long, flexible fiberscopes. A peroral colonoscope has been used for small-bowel enteroscopy and biopsy. A pediatric colonoscope for jejunoscopy has been described. Herein we report a patient undergoing percutaneous transhepatic decompression for the extrahepatic biliary obstruction in whom the guidewire broke and was lost in the liver. The proximal end of the wire was within the liver, while the distal end exited the ampulla and lay within the upper jejunum. Utilizing a peroral approach with the flexible pediatric colonoscope, we recovered the guidewire without advancing it further into the jejunum, where it may have been lost and have necessitated a celiotomy.
extended from the intrahepatic biliary system through the ampulla of Vater into the proximal jejunum (Fig. 1). The Surgical and Gastroenterology Services determined that endoscopic removal of the guidewire would be preferable. Attempts with the Olympus panendoscope GIFQ 10 and crocodile, clawedhook, and blunted-hook retriever forceps, grasping the wire where it exited the ampulla or at the junction between the second and third portion of the duodenum, failed to dislodge the wire as the tension created by the position of the wire could not be overcome. During a subsequent attempt in the fluoroscopy suite the pediatric colonoscope, Olympus CFP1OL, was passed per os into the proximal jejunum until the tip of the wire was encountered. An oval polypectomy snare was maneuvered over the tip of the guidewire and then the colonoscope with the wire in tow was withdrawn without incident. There were no complications from the procedure. Subsequent biliary catheter exchange has been performed without incident. After his jaundice subsided the patient was started on chemotherapy and was discharged to his home in satisfactory condition.
Key words: Percutaneous biliary stenting - Exchange using guidewire- Jejunoscopy for foreign b o d i e s Peroral colonoscope
Case report J.K. is a 71-year-old Caucasian male with a history of cough, hemoptysis, and dyspnea who was referred for evaluation of a left lung nodule. On physical examination, he was found to be jaundiced. He had decreased breath sounds with scattered ronchi, an enlarged liver at 3 cm below the right costal margin, and quaiac-positive stools. Abdominal ultrasonography and computed tomography revealed a retroperitoneal mass extending into the porta hepatis with dilated biliary ducts. At celiotomy the mass appeared to be completely obstructing the common bile duct, and biopsy revealed diffuse histiocytic lymphoma. A choledochoenteric bypass was not technically possible. Postoperatively, decompression of the biliary tree was accomplished by percutaneous insertion of an #8-Fr 40-side-hole catheter. During a subsequent attempt to exchange the biliary catheter, the exchange wire fractured in the liver parenchyma. The guidewire
Present address and address for offprint requests: D.N. Reed, Jr., Department of Surgery, McLaren Regional Medical Center, 401 South Ballenger Highway, Flint, MI 48532, USA
Fig. 1. Abdominal x-ray showing the retained PTC guidewire (arrow)
37
Discussion
Most previous reports of small-intestine endoscopy have promoted the use of specially designed long fiberscopes [3, 4, 5, 7]. Iida et al. suggested the addition of a "stiffening sleeve" over a forward-viewing duodenofiberscope of the Olympus GIF series as an aid for jejunal endoscopy [8]. However, 3 years earlier Parker and Agayoff published an article describing small-intestine enteroscopy and biopsy using a colonoscope perorally [6], and in 1985 Barkin et al. suggested use of the pediatric colonoscope [2]. We present a case in which the flexible pediatric colonoscope was passed per os into the jejunum with successful retrieval of a lost guidewire without advancing the latter. The obvious advantages here are: first, a lost PTC guidewire was retrieved without laparotomy, saving the patient from additional risk. Second, the upper jejunum was reached by using the readily available flexible pediatric colonoscope, rather than a specially designed endoscope or sleeve. Third, the guidewire did not have to be advanced as has been previously suggested, which might have resulted in loss of the guidewire further down the gastrointestinal tract. Upper gastrointestinal use of the flexible colonoscope has even been described for placement of feeding jejunostomy tubes [1]. With our radiologic colleagues increasing the availability of percutaneous
biliary stenting for malignant common duct obstruct i o n s - a n d exchanging those tubes later over a guidewire--this is likely to be a problem that surgeons may be called upon to resolve. The authors feel the abovedescribed technique may be of particular use, given the ready availability of the equipment.
References 1. Adams DB (1991) Feeding jejunostomy with endoscopic guidance. Surg Gynecol Obstet 172:239-241 2. Barkin JS, Schonfeld W, Thomsen S, Manten HD, Rogers AI (1985) Enteroscopy and small bowel biopsy--an improved technique for the diagnosis of small bowel disease. Gastrointest Endosc 31:215-217 3. Classen M, Frfihmorgen P, Koch H, Demling L (1972) Fiberoptic endoscopy of the jejunum and ileum (Dtsch). Dtsch Med Wochenschr 97:409-411 4. Deyhle P, Jenny S, Fumagalli J, Linder E, Ammann R (1972) Endoscopy of the whole small intestine. Endoscopy 4:155-157 5. Ogoshi K, Hara Y, Ashizawa S (1973) New technic for small intestinal fiberoscopy. Gastrointest Endosc 20:64-65 6. Parker HW, Agayoff JD (1983) Enteroscopy and small bowel biopsy utilizing a peroral colonoscope. Gastrointest Endosc 29: 139-140 7. Tada M, Akasake Y, Misaki F, Kawai K (1977) Clinical evaluation of a sonde-type small intestinal fiberscope. Endoscopy 9: 3338 8. Iida M, Yamamoto T, Yao T, Fuchigami T, Fujishima M (1986) Jejunal endoscopy using a long duodenofiberscope. Gastrointest Endosc 32:233-236
Surgical Endoscopy © Springer-VerlagNew York Inc. 1992
Peroral enteroscopic removal of a retained percutaneous transhepatic guidewire from the jejunum using a colonoscope Donald N. Reed, Jr. 1, Joseph C. Young l, Ricardo J. Mitre 2, and Robert Pagano 2 Divisions of ~General Surgery and 2 Gastroenterology, Allegheny General Hospital, Pittsburgh, PA 15212, USA
Summary. Several authors have described the ability to perform small-intestine endoscopy with long, flexible fiberscopes. A peroral colonoscope has been used for small-bowel enteroscopy and biopsy. A pediatric colonoscope for jejunoscopy has been described. Herein we report a patient undergoing percutaneous transhepatic decompression for the extrahepatic biliary obstruction in whom the guidewire broke and was lost in the liver. The proximal end of the wire was within the liver, while the distal end exited the ampulla and lay within the upper jejunum. Utilizing a peroral approach with the flexible pediatric colonoscope, we recovered the guidewire without advancing it further into the jejunum, where it may have been lost and have necessitated a celiotomy.
extended from the intrahepatic biliary system through the ampulla of Vater into the proximal jejunum (Fig. 1). The Surgical and Gastroenterology Services determined that endoscopic removal of the guidewire would be preferable. Attempts with the Olympus panendoscope GIFQ 10 and crocodile, clawedhook, and blunted-hook retriever forceps, grasping the wire where it exited the ampulla or at the junction between the second and third portion of the duodenum, failed to dislodge the wire as the tension created by the position of the wire could not be overcome. During a subsequent attempt in the fluoroscopy suite the pediatric colonoscope, Olympus CFP1OL, was passed per os into the proximal jejunum until the tip of the wire was encountered. An oval polypectomy snare was maneuvered over the tip of the guidewire and then the colonoscope with the wire in tow was withdrawn without incident. There were no complications from the procedure. Subsequent biliary catheter exchange has been performed without incident. After his jaundice subsided the patient was started on chemotherapy and was discharged to his home in satisfactory condition.
Key words: Percutaneous biliary stenting - Exchange using guidewire- Jejunoscopy for foreign b o d i e s Peroral colonoscope
Case report J.K. is a 71-year-old Caucasian male with a history of cough, hemoptysis, and dyspnea who was referred for evaluation of a left lung nodule. On physical examination, he was found to be jaundiced. He had decreased breath sounds with scattered ronchi, an enlarged liver at 3 cm below the right costal margin, and quaiac-positive stools. Abdominal ultrasonography and computed tomography revealed a retroperitoneal mass extending into the porta hepatis with dilated biliary ducts. At celiotomy the mass appeared to be completely obstructing the common bile duct, and biopsy revealed diffuse histiocytic lymphoma. A choledochoenteric bypass was not technically possible. Postoperatively, decompression of the biliary tree was accomplished by percutaneous insertion of an #8-Fr 40-side-hole catheter. During a subsequent attempt to exchange the biliary catheter, the exchange wire fractured in the liver parenchyma. The guidewire
Present address and address for offprint requests: D.N. Reed, Jr., Department of Surgery, McLaren Regional Medical Center, 401 South Ballenger Highway, Flint, MI 48532, USA
Fig. 1. Abdominal x-ray showing the retained PTC guidewire (arrow)
37
Discussion
Most previous reports of small-intestine endoscopy have promoted the use of specially designed long fiberscopes [3, 4, 5, 7]. Iida et al. suggested the addition of a "stiffening sleeve" over a forward-viewing duodenofiberscope of the Olympus GIF series as an aid for jejunal endoscopy [8]. However, 3 years earlier Parker and Agayoff published an article describing small-intestine enteroscopy and biopsy using a colonoscope perorally [6], and in 1985 Barkin et al. suggested use of the pediatric colonoscope [2]. We present a case in which the flexible pediatric colonoscope was passed per os into the jejunum with successful retrieval of a lost guidewire without advancing the latter. The obvious advantages here are: first, a lost PTC guidewire was retrieved without laparotomy, saving the patient from additional risk. Second, the upper jejunum was reached by using the readily available flexible pediatric colonoscope, rather than a specially designed endoscope or sleeve. Third, the guidewire did not have to be advanced as has been previously suggested, which might have resulted in loss of the guidewire further down the gastrointestinal tract. Upper gastrointestinal use of the flexible colonoscope has even been described for placement of feeding jejunostomy tubes [1]. With our radiologic colleagues increasing the availability of percutaneous
biliary stenting for malignant common duct obstruct i o n s - a n d exchanging those tubes later over a guidewire--this is likely to be a problem that surgeons may be called upon to resolve. The authors feel the abovedescribed technique may be of particular use, given the ready availability of the equipment.
References 1. Adams DB (1991) Feeding jejunostomy with endoscopic guidance. Surg Gynecol Obstet 172:239-241 2. Barkin JS, Schonfeld W, Thomsen S, Manten HD, Rogers AI (1985) Enteroscopy and small bowel biopsy--an improved technique for the diagnosis of small bowel disease. Gastrointest Endosc 31:215-217 3. Classen M, Frfihmorgen P, Koch H, Demling L (1972) Fiberoptic endoscopy of the jejunum and ileum (Dtsch). Dtsch Med Wochenschr 97:409-411 4. Deyhle P, Jenny S, Fumagalli J, Linder E, Ammann R (1972) Endoscopy of the whole small intestine. Endoscopy 4:155-157 5. Ogoshi K, Hara Y, Ashizawa S (1973) New technic for small intestinal fiberoscopy. Gastrointest Endosc 20:64-65 6. Parker HW, Agayoff JD (1983) Enteroscopy and small bowel biopsy utilizing a peroral colonoscope. Gastrointest Endosc 29: 139-140 7. Tada M, Akasake Y, Misaki F, Kawai K (1977) Clinical evaluation of a sonde-type small intestinal fiberscope. Endoscopy 9: 3338 8. Iida M, Yamamoto T, Yao T, Fuchigami T, Fujishima M (1986) Jejunal endoscopy using a long duodenofiberscope. Gastrointest Endosc 32:233-236
