Management of simultaneous biliary and duodenal obstruction the endocopic perspective

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  • 1. Gut and Liver, Vol. 4, Suppl. 1, September 2010, pp. S50-56 ReviewManagement of Simultaneous Biliary and Duodenal Obstruction:The Endoscopic PerspectiveTodd H. BaronDivision of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA1Obstructive jaundice often develops in patients withdenal obstruction the survival time is shorter. Duringunresectable malignancy in and around the head of this period treatment should focus on palliation of symp-the pancreas. Duodenal obstruction can also occur intoms of obstructive jaundice, duodenal obstruction andthese patients, and usually develops late in the dis- pain. Controversy exists about how to provide the opti-ease course. Palliation of both malignant biliary and mal palliative treatment. Both surgical and non-surgicalduodenal obstruction is traditionally performed withpalliative procedures can be used to relieve obstructivesurgical diversion of the bile duct and stomach, re-jaundice and duodenal obstruction. Surgical palliation isspectively. With the advent of nonsurgical palliation ofachieved by biliary and gastric diversion through the crea-biliary obstruction using endoscopic transpapillary ex-pandable metal stent placement, a similar approachtion of choledochojejunal and gastrojejunal anastomoses,can be used to palliate duodenal obstruction by place-respectively.ment of expandable metal gastroduodenal stents. En-Endoscopic placement of self-expandable metal stents2doscopic palliation can be achieved in patients who (SEMS) has been used to palliate biliary and duodenal 3require relief of both biliary obstruction and duodenal obstruction. It is known that many patients who requireobstruction, although this can be technically difficult toduodenal stent placement also have undergone or will re-achieve depending on the level of duodenal obstruc-4quire subsequent palliation of biliary obstruction. In thistion in relation to the major papilla. This article re- article the endoscopic methods used for combined reliefviews the endoscopic approaches for combined pallia-of both malignant biliary and duodenal obstruction willtive relief of malignant biliary and duodenal obstruc-be reviewed.tion. (Gut Liver 2010;4(Suppl. 1):S50-56)Key Words: Duodenal obstruction; Endoscopy, gas-ANATOMIC AND CLINICAL SCENARIOStrointestinal; Palliative care; Stents; CholestasisAnatomic and clinical scenarios determine the endo-scopic approach to the palliative management of patientsINTRODUCTIONwith both biliary and duodenal obstruction and will bediscussed separately.Patients with pancreatic and peri-pancreatic cancer (in-1. Anatomic scenarios of biliary and duodenal ob-cluding, ampullary cancer, cholangiocarcinoma, gallbladder structioncancer and metastatic lesions in and around the head ofpancreas) are usually diagnosed at an advanced stage in The location of the duodenal obstruction in relation towhich curative resection is impossible. The median sur- the major papilla is the major determinant to successfulvival rate of patients with non-resectable peri-pancreaticendoscopic simultaneous palliation of biliary and duode-cancer varies widely and can be as long as 6 to 12nal obstruction since the duodenal obstruction can limit 1months. However, in the setting of both biliary and duo-access to the biliary opening. Mutignani et al. proposed aCorrespondence to: Todd H. BaronDivision of Gastroenterology and Hepatology, Department of Medicine, 200 First St. SW, Rochester, MN 55905, USATel: +1-507-284-2174, Fax: +1-507-255-7612, E-mail: todd@mayo.eduDOI: 10.5009/gnl.2010.4.S1.S50

2. Baron TH: Management of Simultaneous Biliary and Duodenal Obstruction: The Endoscopic Perspective S51classification system for the three anatomic scenarios of duodenal palliation is least in patients with type III duo-duodenal obstruction in relation to the major papilla thatdenal stenosis while type I is intermediate and type II isdetermine the endoscopic approach and technical success the most technically difficult.to combined palliation of biliary and duodenal obstruc-The approach to type I cases is to pass the duodeno-tion. The classification system is as follows (Fig. 1): scope through the duodenal stricture to the major papilla,Type I stenosis occurs at the level of the duodenal bulbif possible. This may require balloon dilation of the stric-or upper duodenal genu but without involvement of the ture to a diameter of 15-18 mm (Fig. 2A) and/or passingpapilla. Type II stenosis affects the second part of the du-the balloon to the third duodenum to be used as an an-5odenum with involvement of the major papilla. Type IIIchor to pull the endoscope across the stricture. Once thestenosis involves the third part of the duodenum distal tomajor papilla is reached the biliary tree is cannulated andand without involvement of the major papilla. an expandable metal biliary stent is placed (Fig. 2B). A Of the three types of biliary-duodenal stenoses, techni- guidewire is then advanced through the channel of thecal difficulty to achieve successful combined biliary and endoscope and passed into the fourth portion of the duo-denum; the duodenoscope is withdrawn into the stomachand a duodenal stent which passes through the workingchannel of the endoscope is deployed across the duodenal6stricture as previously described (Fig. 2C). It is usuallynecessary to place the proximal end of the stent into thestomach to allow enough stent coverage of the duodenalstricture since type I strictures tend to be in the proximalduodenal bulb. If the duodenoscope cannot be advancedthrough the stricture despite balloon dilation a duodenalstent is placed across the stricture. Since the luminal di-ameter of commercially available duodenal stents is 20-22mm and duodenoscopes are approximately 11 mm, theendoscope can usually be passed through the stent duringthe same procedure to allow the biliary system to be ac-cessed with placement of a biliary SEMS. However, thismay require balloon dilation of the duodenal stent. It isimportant that the duodenal stent be placed with the dis-tal end positioned proximal to the level of the major pap-illa to allow the bile duct to be accessed (Fig. 3). The lo-cation of the major papilla can be estimated easily fluo-roscopically in the presence of a prior biliary stent or bypassing a smaller caliber forward-viewing endoscope tothe papilla and a obtaining a radiographic image with theendoscope positioned at the level of the papilla for laterreference. If the duodenoscope cannot be passed throughthe duodenal stent lumen because of inadequate stent ex-pansion despite balloon dilation there are three options.The first option is to repeat the endoscopic retrogradecholangiopancreatography (ERCP) after waiting at least48 to 72 hours at which time the duodenal stent is al-most always fully expanded and will allow passage of theduodenoscope to the second duodenum. Other options toFig. 1. Classification of duodenal stenosis type in relation to palliate biliary obstruction include percutaneous access tothe major papilla as proposed by Mutignani et al. Endoscopy the biliary tree and endoscopic ultrasound (EUS)-guided12007;39:440-447. : (I) at the level of the duodenum proximalentry into the biliary tree (both of these approached willto and without involvement of the papilla, (II) affecting the be discussed in more detail below under management ofsecond part of the duodenum with involvement of the majortype II duodenal obstruction).papilla, and (III) involving the third part of the duodenumdistal to and without involvement of the major papilla.The approach to type II cases is most difficult. The sec- 3. S52Gut and Liver, Vol. 4, Suppl. 1, September 2010Fig. 2. Palliation of biliary and duodenal obstruction in type I stenosis. (A) The duodenal stricture is balloon dilated to allowpassage of the duodenoscope to the level of the major papilla (note the prior placement of a plastic biliary stent). (B) After theendoscope is passed to the major papilla, the plastic stent is removed and an expandable metal biliary stent is deployed. (C) Afterdeployment of the biliary stent, an expandable metal duodenal stent is placed.Fig. 3. Type I duodenal stenosiswith duodenal stent placementto allow access to the bile duct.(A) The duodenal stent ispositioned with the distal endproximal to the major papilla(arrow) as visualized using anupper endoscope. (B) In thesame patient, the endoscopehas been passed through theduodenal stent (arrowheads)lumen and an expandable metalbiliary stent (arrows) is placed.ond duodenum is strictured and involves the major major papilla can be identified through the interstices ofpapilla. Unless the patient has had a prior transpapillarythe duodenal stent and the bile duct accessed with place-biliary stent placed, bile duct cannulation is often notment of a biliary SEMS. If the bile duct cannot be ac-successful since the major papilla is not endoscopicallycessed through a transpapillary approach after duodenalidentifiable due to extensive tumor infiltration. In addi-stent placement then biliary access can be achieved using 7tion, the lumen is narrowed and there is little working a percutaneous or EUS approach. Typically, in either ofroom between the lens of the endoscope and the majorthe two approaches the bile duct is accessed through thepapilla. Nonetheless, one should first attempt placementliver (when EUS is used a transgastric approach is mostof an expandable metal biliary stent. If successful, the du-often used). In addition, in either approach there are twoodenal stent is then placed across the stricture and over-options: a rendezvous approach or completion alone usinglies the biliary stent. If identification and/or cannulationa percutaneous or EUS approach. When the rendezvousof the major papilla cannot be achieved then a duodenal approach is used, a guidewire is passed into the biliarystent is placed across the stricture. Unfortunately, thetree across the stri