Biliary - Cholangiocarcinoma, bilateral plastic stent placement
Comments: This is a demonstration of ERCP with endoscopic placement of a bilateral biliary plastic stents in an active 94 year old physician with known Klatskin tumor. The patient presented acutely with a new onset of fever, jaundice, and right upper quadrant pain, suggestive of cholangitis. The patient had previously decided against surgical intervention or radiation therapy at the time of the original diagnosis, approximately 6 months prior to this presentation. An ERCP was performed to provide therapy of acute cholangitis. A balloon catheter was selected for an occlusion cholangiogram because of the history of a prior biliary sphincterotomy. The cholangiogram demonstrates easy filling of the right hepatic ductal system and slower filling of the left ductal system with strictures of the left and right hepatic ducts consistent with the diagnosis of a cholangiocarcinoma. The goal of therapy is to first place two biliary guidewires into the left and right biliary systems with subsequent placement of stents in the right and left systems. A wire is seen advancing into the left system. Once the wire was successfully placed across the left hepatic stricture, a second wire is introduced through a pull type sphincterotome into the right hepatic system. This cholangiogram demonstrates successful placement of two wires into the left and right ductal systems. Once the wires are placed in a good position across the hilar strictures, a 10 fr biliary stent can be seen advancing into the left biliary system. Care should be given not to displace the second wire during this process. There is often increased difficulty advancing the stent through the strictured area. Attention should be given to keep a short distance between the tip of the endoscope and the ampulla. This allows the maximum mechanical advantage to advance the stent through the stricture. The stent is now successfully deployed and using fluoroscopic visualization to document the stent has been placed above the stricture. Note that the endoscope is in the short position which best facilitates successful placement of the stent. One now can see copious amounts of pus draining from the left biliary stent. The second wire which is in the right system is noted to be securely in place. The finding of pus confirms the diagnosis of acute cholangitis. Next a second 10 fr stent is being placed into the right system which did not appear to be as obstructed as the left system. Care should be given not to disrupt the already placed biliary stent. Once the stent has been confirmed to be above the stricture using fluoroscopy, the stent is deployed with removal of the inner guide catheter. Now relatively normal appearing bile can be seen draining from the right system, suggesting that this paitent had actue cholangitis as a result of obstruction of the left biliary system. With the help of iv antibiotics, the patient's cholangitis resolved. The patient was discharged without complications. If the patient has recurrent obstruction, metal stents will replace the plastic stents.
| Contributed by: |
Anthony Kalloo, M.D. Chief of Gastroenterology Johns Hopkins Medical Center |
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Citation: Kalloo, A. (Mar 09 2006). Biliary - Cholangiocarcinoma, bilateral plastic stent placement. The DAVE Project. Retrieved Feb, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=377 Times viewed since Feb 2006: 8654 |
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