SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer

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Transcript of SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer

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    BILIARY-ENTERIC OBSTRUCFROM RECURRENT CANC

    Resident(s): Osama Abdul-RahimAttending(s): Jeffrey Weinstein

    Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

    Originally Posted:

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    CHIEF COMPLAINT & HPI

    Chief Complaint and/or reason for consultation Abdominal pain

    History of Present Illness

    57 y/o male with pancreatic adenocarcinoma s/p Whipple 8 moprior presents with abdominal pain

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    RELEVANT HISTORY

    Past Medical History Spinal stenosis Hypertension GERD

    Arthritis Anxiety

    Past Surgical History Jaw surgery, Whipple

    Family & Social History 1 pack/day x 40 years, no EtOH or drug use

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    DIAGNOSTIC WORKUP

    Physical Exam Mild right upper quadrant tenderness to palpation

    Laboratory Data Total Bilirubin: 7 mg / dL

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    DIAGNOSTIC WORKUP - IMAGING

    Pancreatic adenocarcinoma

    prior to Whipple

    1 month s/p Whipple - No l

    disease recurren

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    DIAGNOSTIC WORKUP - IMAGING

    8 months post Whipple there is a mass in right perinephric space (gre

    causing afferent limb (yellow arrow) and biliary ductal dilatation (re

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    DIAGNOSIS

    Metastatic pancreatic adenocarcinoma

    CT abdomen and pelvis shows recurrent tumor in the righperinephric space

    Resultant mass effect is obstructing the afferent jejunal lcausing secondary biliary obstruction, indicated by theintrahepatic bile duct dilatation and elevated bilirubin

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    INTERVENTION

    Left hepatic internal/external percutaneous

    biliary drain was placed

    3 days later, ductal dilatation

    afferent jejunal limb rem

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    INTERVENTION

    Transhepatic enterography shows persistent afferent

    limb obstruction due to extrinsic compressionGuidewire was advanced

    obstruction

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    INTERVENTION

    Initially, an 18 x 60 mm Wallstent was placed. Due

    to foreshortening, it was thought to be too shortA 14 x 100 mm Nitinol stent was dWallstent. Contrast flowed freely

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    CLINICAL FOLLOW UP

    Follow up CT showed improvement in bothbiliary ductal and afferent jejunal limbdilatation after intervention

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    QUESTION 1

    1) Why was endoscopic guided therapy less feasible in this scenario

    A: Endoscopy is not indicated for biliary obstruction.

    B: Endoscopy can never be performed following a Whipple procedure.

    C: Endoscopy is technically challenging following a Whipple procedure.

    D: Whats endoscopy?

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    SORRY, THATS INCORRECT.

    1) Why was endoscopic guided therapy less feasible in this scenario?

    A: Endoscopy is not indicated for biliary obstruction. (Endoscopy is often a good oevaluation and treatment of biliary obstruction)

    B: Endoscopy can never be performed following a Whipple procedure. (Endoscopsometimes possible following a Whipple and requires a double-balloon techniquedifficult however and often unsuccessful.)

    C: Endoscopy is technically challenging following a Whipple procedure. (Due t

    anatomic alterations resulting from a Whipple complicating the endoscopic aptranshepatic approach to a dilated biliary system was a good choice for intervthis patient.)

    D: Whats endoscopy? (Small, flexible camera that enters the mouth or anus and cthrough the proximal small bowel or colon, respectively, allowing direct visualizatpossible therapeutic intervention.)

    CONTINUE WITH CASE

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    CORRECT!

    1) Why was endoscopic guided therapy less feasible in this scenario?A: Endoscopy is not indicated for biliary obstruction.

    B: Endoscopy can never be performed following a Whipple procedure.

    C: Endoscopy is technically challenging following a Whipple procedure.Although endoscopy is often a good option for evaluation and treatme

    biliary obstruction, due to the anatomic alterations resulting from a Whalthough endoscopy is sometimes possible using a double-balloon techis very difficult and often unsuccessful.

    D: Whats endoscopy?

    CONTINUE WITH CASE

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    QUESTION 2

    What are some of the more common uses of stents in the GI tract?

    A: Esophagus

    B: Stomach

    C: Common Bile Duct

    D: Colon

    E: All of the above

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    CORRECT!

    What are some of the more common uses of stents in the GI tract?

    A: Esophagus (Can be used for palliation of dysphagia from esophaggastric cardia cancer, tracheoesophageal fistula, esophageal rup

    B: Stomach (Gastric outlet obstruction, pseudocyst drainage)

    C: Common Bile Duct (Relieve obstruction or leak)

    D: Colon (Relieve obstruction either as a bridge to surgery or for palliation)

    E: All of the above

    CONTINUE WITH CASE

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    SORRY, THATS INCORRECT.

    What are some of the more common uses of stents in the GI tract?A: Esophagus (Can be used for palliation of dysphagia from esophag

    gastric cardia cancer, tracheoesophageal fistula, esophageal rup

    B: Stomach (Gastric outlet obstruction, pseudocyst drainage)

    C: Common Bile Duct (Relieve obstruction or leak)

    D: Colon (Relieve obstruction either as a bridge to surgery or for palliation)

    E: All of the above

    CONTINUE WITH CASE

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    SUMMARY & TEACHING POINTS

    57 y/o male with recurrent metastatic pancreaticadenocarcinoma s/p Whipple causing afferent jejunal lim

    biliary obstruction

    Biliary obstruction was initially relieved with internal/ex

    percutaneous transhepatic biliary drain placement

    Persistent afferent jejunal limb obstruction was subsequ

    successfully relieved by placing an enteric stent

    transhepatically

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    REFERENCES

    Lee JM, Han YM, Lee SY, Kim CS, Yang DH, Lee SO. Palliation of postoper

    gastrointestinal anastomotic malignant strictures with flexible covered mestents: preliminary results.Cardiovasc Intervent Radiol 2001;24:25-30.

    Yim HB, Jacobson BC, Saltzman JR, Johannes RS, Bounds BC, Lee JH, et outcome of the use of enteral stents for palliation of patients with malignanGI obstruction. Gastrointest Endosc 2001;53:329-32.

    Feretis C, Benakis P, Dimopoulos C, Manouras A, Tsimbloulis B, ApostolidN. Duodenal obstruction caused by pancreatic head carcinoma: palliation wexpandable endoprostheses. Gastrointest Endosc 1997;46:161-5