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

8/21/2019 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:



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



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



DIAGNOSTIC WORKUP

Physical Exam Mild right upper quadrant tenderness to palpation

Laboratory Data Total Bilirubin: 7 mg / dL



DIAGNOSTIC WORKUP - IMAGING

Pancreatic adenocarcinoma

prior to Whipple

1 month s/p Whipple - No l

disease recurren



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



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



INTERVENTION

Left hepatic internal/external percutaneous

biliary drain was placed

3 days later, ductal dilatation

afferent jejunal limb rem



INTERVENTION

Transhepatic enterography shows persistent afferent

limb obstruction due to extrinsic compressionGuidewire was advanced

obstruction



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



CLINICAL FOLLOW UP

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



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: What’s endoscopy?



SORRY, THAT’S 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: What’s 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



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: What’s endoscopy?

CONTINUE WITH CASE



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



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



SORRY, THAT’S 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



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



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

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

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