and pancreatic enzyme elevation associated with SOM.
6 5
~
REFERENCES
4
Z
o o
LU
3
C/)
2
ASPIRATED
NON-ASPIRATED
N= 17 Figure 4. Effect of aspiration on pancreatic sphincter of Oddi phasic duration. A line connects the pancreatic sphincter of Oddi phasic duration determined by the aspirated and nonaspirated techniques (difference, not significant).
trol" data would be of great interest, it might still put the person at risk for pancreatitis. 4 We conclude that the pressure dynamics of the sphincter of Oddi are unaltered by aspiration of pancreatic duct fluid. A randomized prospective study is being conducted to determine if the modified aspirated catheter reduces the frequency of clinical pancreatitis
Endoscopic biliary decompression aided by a different technique of percutaneous transhepatic access Mark Jacobs, MD
Since first reported in 1978, the non-operative, percutaneous placement of a biliary prosthesis for relief of obstructive jaundice has provided an effective means of palliating malignant strictures. 1- 3 The placement of internal biliary stents has decreased the incidence of complications associated with long-term external drainage. The two technical approaches that initially evolved used either the percutaneous or the Received September 7, 1989. For revision November 16, 1989. Accepted March 12,1990. From the Departments of Medicine, Division of Gastroenterology, Mercy Catholic Medical Center, Darby, Pennsylvania and Delaware County Memorial Hospital, Drexel Hill, Pennsylvania. Reprint requests: Mark Jacobs, MD, 1010 West Chester Pike, Havertown, Pennsylvania 19083. VOLUME 36, NO.5, 1990
1. Lebovics E, Heier SK, Rosenthal WS. Chronic pancreatitis and the sphincter of Oddi: which is the numerator and which the denominator? Am J Gastroenterol 1988;83:854-6. 2. Guelrud M. Papillary stenosis. Endoscopy 1988;20:193-202. 3. Toouli J. What is sphincter of Oddi dysfunction? Gut 1989;30:753-61. 4. Albert MB, Steinberg WM, Irani SK. Severe acute pancreatitis complicating sphincter of Oddi manometry. Gastrointest Endosc 1988;34:342-5. 5. King CE, Kalvaria I, Sninsky CA. Pancreatitis due to endoscopic biliary manometry: proceed with caution. Gastroenterology 1988;94:A227. 6. Cattau EL Jr, Johnson DA, Benjamin SB, Geenen JE, Hogan WJ. Sphincter of Oddi (SO) manometry: a survey of methodology, complications and clinical applications [Abstract). Gastrointest Endosc 1988;34:185. 7. Gregg JA. Function and dysfunction of the sphincter of Oddi. In: Jacobson 1M, ed. ERCP: diagnostic and therapeutic applications. New York: Elsevier Science Publishing Co., 1989:13970. 8. Geenen JE, Hogan WJ, Dodds WJ, Stewart ET, Arndorfer RC. Intraluminal pressure recordings from the human sphincter of Oddi. Gastroenterology 1980;78:317-24. 9. Carr-Locke DL, Gregg J A. Endoscopic manometry of pancreatic and biliary sphincter zones in man: basal results in healthy volunteers. Dig Dis Sci 1981;26:7-15. 10. Gregg JA. The intraductal secretin test: an adjunct to ERCP. Gastrointest Endosc 1982;28:199-203. 11. Summers RW, Johlin FC. The pathophysiology, evaluation and management of motility disorders of the biliary tract. Gastroenterol Clin North Am 1989;18:425-35. 12. Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Venu RP. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter of Oddi dysfunction. N Engl J Med 1989;320:82-7.
endoscopic approach. The combined percutaneousendoscopic techniques previously described4 - 1o used advantages of each. The combined percutaneous-endoscopic technique evolved over the last several years. Initially, the endoscopist used a forward viewing endoscope to grasp the percutaneous wire and pull it out through the mouth as the instrument was removed. Then, by using a pusher tube, the stent was placed through the ampullary o'rifice using only radiographic guidance. This technique was hampered by difficulty with stent positioning, occasionally causing the stent to enter the hepatic parenchema. The radiologist would then be required to place a large bore pusher tube through the liver to reposition the stent, thereby increasing the risk of liver injury. A second technique involved grasping the percutaneously placed wire through the therapeutic ERCP endoscope and pulling it through the instrument. This enables the endoscopist to achieve better control by 503
direct endoscopic visualization of the placement of the stent and also allows a full array of endoscopic therapeutic maneuvers, including sphincterotomy. However, the wire, when pulled through the endoscope, has a kink at the tip. Furthermore, the passage of a wire through the acutely flexed and angled tip of the endoscope produces torque and deformity of the wire making passage of the stent over the deformed wire more difficult. This report describes a modified technique for percutaneous-endoscopic therapeutic ERCP which was used in 12 patients. The method provides an intact wire while maintaining all of the advantages of endoscopic visualization. METHOD
All patients with obstructive jaundice that had failed endoscopic cannulation or endoscopic placement of a wire because of papillary stenosis or biliary stricture underwent a standard percutaneous-transhepatic cholangiogram, performed by established techniques,"-13 and an external drain was placed to establish a tract. At the onset of the combined procedure, the obstructed bile duct was cannulated with a O.038-inch guide wire followed by the placement of a 6 F catheter transhepatically into the duodenum. At this point, an Olympus TJF-lO therapeutic ERCP instrument (Olympus Corporation, Lake Success, N.Y.) was passed into the duodenum. When the percutaneous catheter was identified at the ampulla of Vater, the transhepatic catheter was exchanged by standard technique for a wire basket stone retriever (Wilson-Cook Medical Inc., Winston-Salem, N.C.). The radiologist opened the basket within the duodenum, and a 400-cm-Iong, O.035-inch guide wire was placed through the endoscope into the open basket. While the endoscopist observed to ensure the absence of duodenal mucosal trauma, the basket was closed and withdrawn and the wire guide was pulled through the biliary tree and secured externally by the radiologist. If stone extraction was required, a wire-guided endoscopic sphincterotome (Wilson-Cook Medical, Inc.) was passed and sphincterotomy was performed to facilitate the removal of common bile duct stones. This was done with the wire guide left transhepatically in position, secured by a clamp held by the gloved hand of the radiologist. If an endoscopic stent was required, by standard endoscopic techniques,14.15 10 F Cotton-Leung prostheses (Wilson-Cook Medical, Inc.) were placed under endoscopic and fluoroscopic guidance. It was not necessary to perform a sphincterotomy to facilitate stent passage. The pusher tube was passed through the endoscope, and the proper position of the stent barb was confirmed by direct endoscopic visualization. When both the radiologist and the endoscopist were satisfied with the position of the stent, the radiologist released the guide wire, which was pulled back through the endoscope by the endoscopist. Removal of the pusher tube and endoscope completed the procedure.
RESULTS
From January 1987 through May 1989, 12 patients with endoscopically non-accessible biliary tract pa504
thology underwent combined percutaneous-endoscopic therapeutic biliary manipulation. All of the patients had refused surgery or were considered poor surgical risks. Ten of the patients underwent endoscopic biliary stent placement for malignancy and two for removal of common duct stones. The latter two patients each underwent sphincterotomy. One of these had undergone prior Billroth II gastrectomy. One patient developed a bile leak and perihepatic collection that required percutaneous drainage and eventual surgery. A second patient, who was considered a poor surgical risk with severe vascular insufficiency, short bowel syndrome, and multisystem failure, aspirated during the procedure and died 6 days later. The remaining 10 patients tolerated the procedure well without complication. DISCUSSION
The relative roles of the endoscopic versus the percutaneous approach to relieving obstructed biliary ducts remain open to discussion. The concern for complications such as pain, bile peritonitis, liver trauma, and bleeding associated with the placement of large bore catheters through the liver 16 has been offset somewhat by the generally easier accessibility of the percutaneous approach to the obstructed biliary tree. The technique of the combined approach as described by Tsang et al. 4 has been complicated by difficult assessment of stent positioning, resulting in placement of the stent beyond the ampulla of Vater, and has required the use of a percutaneous large bore pusher tube to reposition the stent. This has increased the risks associated with large catheter penetration of the liver. Another technique, described by Foutch et alY, by using a "push-pull" method resulted in excessive percutaneous manipulation and intraperitoneal bile leak. The technique described by Dowsett et al. 18 resulted in excessive torque and bending of the wire guide, making the procedure technically more difficult. The technique described in this report minimizes the need for percutaneous manipulation and lessens the risk of bile peritonitis. It allows direct visual confirmation of proper positioning of the stent at the ampulla of Vater and confirmation of bile flow. Furthermore, the use of the side-viewing instrument allows passage of various wire-guided sphincterotomes, baskets, dilators, and balloons, extending therapeutic capabilities to include stone retrieval in the most difficult cannulations. In the first 12 patients undergoing this procedure, there was a 100% success rate for relief of biliary obstruction. There were two patients who had major procedure-associated morbidity with one death. The first was a 38-year-old female with multi-system vascular disease who aspirated during the procedure in the face of severe vascular and pulmonary insuffiGASTROINTESTINAL ENDOSCOPY
ciency. She followed a progressive deteriorating course and died 6 days later. The other complication occurred when a polypoid ampullary tumor on a large stalk prevented direct endoscopic visualization of the ampullary orifice, and the stent was pushed too far into the bile duct. This required the use of 10 F pusher tube percutaneously to re-position the stent. Bile leakage and the subsequent need for surgical drainage resulted. More experience and further refinements will be required to continue to decrease the morbidity associated with the combined percutaneous transhepatic cholangiography-ERCP approach to obstructive jaundice. REFERENCES 1. Pereiras RV Jr, Rheingold OJ, Hutson D, et al. Relief of malignant obstructive jaundice by percutaneous insertion of a permanent prosthesis in the biliary tree. Ann Intern Med 1978;89:859-93. 2. Ring EJ, Oleaga JA, Freiman DB, Husted JW, Lunderquist A. Therapeutic application of catheter cholangiography. Radiology 1978;128:333-8. 3. Howels J, Lunderquist A, Inse I. Percutaneous transhepatic intubation of bile ducts for combined internal-external drainage in preoperative and palliative treatment of obstructive jaundice. Gastrointest Radiol 1978;3:23-6. 4. Tsang T, Crampton AR, Bernstein JR, Ramos SR, Weiland J. Percutaneous endoscopic biliary stent placement: a preliminary report. Ann Intern Med 1987;106:339-92. 5. Kerlan RK Jr, Ring EJ, Pogany AC, Jeffrey RB Jr. Biliary endoprosthesis: insertion using a combined peroral-transhepatic method. Radiology 1984;150:828-30. 6. Brambs HJ, Billmann P, Pausch J, Holstege A, lalm R. Nonsurgical biliary drainage: endoscopic conversion of a percuta-
7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
17. 18.
neous transhepatic into an endoprosthetic drain. Endoscopy 1986;18:52-4. Hatfield ARW, Murray RS, Lennard-Jones JE. Periampullary diverticula and common duct calculi-a combined transhepatic and endoscopic technique for difficult cases. Gut 1982;23:A889. Pass RB, Rankin RN. The transhepatic approach to a failed endoscopic sphincterotomy. Gastrointest Endosc 1986;32:221. Mason RR, Cotton PB. Combined duodenoscopic and transpapillary approach to stenosis of the papilla of Vater. Br J Radiol 1981;54:678. Shorvon PJ, Cotton PB, Mason RR, Siegel JH, Hatfield ARW. Percutaneous transhepatic assistance for duodenoscopic sphincterotomy. Gut 1985;26:1373-6. Muller PR, Harbin WP, Ferrucci JT Jr, Wittenberg J, VanSonnenberg E. Fine needle transhepatic cholangiography: reflection from 450 cases. AJR 1981;136:85-90. May GR, Bender CE, Williams HJR, MacCarthy RG. Percutaneous biliary decompression. Semin Intervent Radiol 1985;2:31-30. Cope C. Conversion from small (0.018 inch) to large (0.038 inch) guide wires in percutaneous drainage procedures. AJR 1982;138:170-1. Cotton PB. Duodenoscopic placement of biliary prosthesis to retrieve malignant obstructive jaundice. Br J Surg 1982;69:5013. Soehendra N, Reynders-Frederix V. Palliative duct drainage: a new endoscopic method of introducing a transpapillary drain. Endoscopy 1980;12:8-11. Dolley JS, Dick R, George P, Kirk RM, Hobbs KE, Sherlock S. Percutaneous transhepatic endoprosthesis for bile duct obstruction: complications and results. Gastroenterology 1984;86:9059. Foutch PG, Chinichian A, Talbert G, Sanowski RA. Endoscopic conversion of an external common bile duct stent. Gastrointest Endosc 1987;33:379-81. Dowsett JF, Vaira D, Hatfield ARW, et al. Endoscopic biliary therapy using combined percutaneous and endoscopic technique. Gastroenterology 1989;96:1180-6.
Case Re po rts Submucosal tumors of the terminal ileum managed by endoscopic polypectomy Takayuki Matsumoto, MD Mitsuo lida, MD Toshiyuki Matsui, MD Masahiko Hirakawa, MD Akiko Shiraishi, MD Takashi Yao, MD Masatoshi Fujishima, MD
Submucosal tumors of the terminal ileum are relatively rare. 1- 4 In contrast, submucosal tumors of the colon are increasingly reported, 5 probably because of the development of total colonoscopy. Herein, we report two cases of a submucosal tumor occurring in the From the Departments of Internal Medicine II and Pathology II, Faculty of Medicine, Kyushu University, Fukuoka, Japan. Reprint requests: Takayuki Matsumoto, MD, Second Department of Internal Medicine, Faculty of Medicine, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812, Japan. VOLUME 36, NO.5, 1990
terminal ileum-one being a lipoma, and the other a lymphangioma-both of which were managed by endoscopic polypectomy with a colonofiberscope. Case Reports Case 1
A 72-year-old Japanese man was admitted to our hospital for evaluation of vertigo in September 1985, and he was diagnosed as suffering from basilar insufficiency. During his hospitalization, barium enema was performed and a soft smooth polyp was noted in the ileocecal region (Fig. 1). He had no gastrointestinal tract symptoms. Physical examination and routine laboratory tests revealed no remarkable abnormalities. His fecal occult blood was negative. On abdominal CT examination, a structure with the density of fat tissue, measuring 3 X 2 em, was suspected in the ileocecal region. On total colonoscopy, a pedunculated bilobar yellowish red mass with a smooth surface prolapsed from the terminal ileum through the ileocecal valve after abdominal compression (Fig. 2). The 505
6 5
~
REFERENCES
4
Z
o o
LU
3
C/)
2
ASPIRATED
NON-ASPIRATED
N= 17 Figure 4. Effect of aspiration on pancreatic sphincter of Oddi phasic duration. A line connects the pancreatic sphincter of Oddi phasic duration determined by the aspirated and nonaspirated techniques (difference, not significant).
trol" data would be of great interest, it might still put the person at risk for pancreatitis. 4 We conclude that the pressure dynamics of the sphincter of Oddi are unaltered by aspiration of pancreatic duct fluid. A randomized prospective study is being conducted to determine if the modified aspirated catheter reduces the frequency of clinical pancreatitis
Endoscopic biliary decompression aided by a different technique of percutaneous transhepatic access Mark Jacobs, MD
Since first reported in 1978, the non-operative, percutaneous placement of a biliary prosthesis for relief of obstructive jaundice has provided an effective means of palliating malignant strictures. 1- 3 The placement of internal biliary stents has decreased the incidence of complications associated with long-term external drainage. The two technical approaches that initially evolved used either the percutaneous or the Received September 7, 1989. For revision November 16, 1989. Accepted March 12,1990. From the Departments of Medicine, Division of Gastroenterology, Mercy Catholic Medical Center, Darby, Pennsylvania and Delaware County Memorial Hospital, Drexel Hill, Pennsylvania. Reprint requests: Mark Jacobs, MD, 1010 West Chester Pike, Havertown, Pennsylvania 19083. VOLUME 36, NO.5, 1990
1. Lebovics E, Heier SK, Rosenthal WS. Chronic pancreatitis and the sphincter of Oddi: which is the numerator and which the denominator? Am J Gastroenterol 1988;83:854-6. 2. Guelrud M. Papillary stenosis. Endoscopy 1988;20:193-202. 3. Toouli J. What is sphincter of Oddi dysfunction? Gut 1989;30:753-61. 4. Albert MB, Steinberg WM, Irani SK. Severe acute pancreatitis complicating sphincter of Oddi manometry. Gastrointest Endosc 1988;34:342-5. 5. King CE, Kalvaria I, Sninsky CA. Pancreatitis due to endoscopic biliary manometry: proceed with caution. Gastroenterology 1988;94:A227. 6. Cattau EL Jr, Johnson DA, Benjamin SB, Geenen JE, Hogan WJ. Sphincter of Oddi (SO) manometry: a survey of methodology, complications and clinical applications [Abstract). Gastrointest Endosc 1988;34:185. 7. Gregg JA. Function and dysfunction of the sphincter of Oddi. In: Jacobson 1M, ed. ERCP: diagnostic and therapeutic applications. New York: Elsevier Science Publishing Co., 1989:13970. 8. Geenen JE, Hogan WJ, Dodds WJ, Stewart ET, Arndorfer RC. Intraluminal pressure recordings from the human sphincter of Oddi. Gastroenterology 1980;78:317-24. 9. Carr-Locke DL, Gregg J A. Endoscopic manometry of pancreatic and biliary sphincter zones in man: basal results in healthy volunteers. Dig Dis Sci 1981;26:7-15. 10. Gregg JA. The intraductal secretin test: an adjunct to ERCP. Gastrointest Endosc 1982;28:199-203. 11. Summers RW, Johlin FC. The pathophysiology, evaluation and management of motility disorders of the biliary tract. Gastroenterol Clin North Am 1989;18:425-35. 12. Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Venu RP. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter of Oddi dysfunction. N Engl J Med 1989;320:82-7.
endoscopic approach. The combined percutaneousendoscopic techniques previously described4 - 1o used advantages of each. The combined percutaneous-endoscopic technique evolved over the last several years. Initially, the endoscopist used a forward viewing endoscope to grasp the percutaneous wire and pull it out through the mouth as the instrument was removed. Then, by using a pusher tube, the stent was placed through the ampullary o'rifice using only radiographic guidance. This technique was hampered by difficulty with stent positioning, occasionally causing the stent to enter the hepatic parenchema. The radiologist would then be required to place a large bore pusher tube through the liver to reposition the stent, thereby increasing the risk of liver injury. A second technique involved grasping the percutaneously placed wire through the therapeutic ERCP endoscope and pulling it through the instrument. This enables the endoscopist to achieve better control by 503
direct endoscopic visualization of the placement of the stent and also allows a full array of endoscopic therapeutic maneuvers, including sphincterotomy. However, the wire, when pulled through the endoscope, has a kink at the tip. Furthermore, the passage of a wire through the acutely flexed and angled tip of the endoscope produces torque and deformity of the wire making passage of the stent over the deformed wire more difficult. This report describes a modified technique for percutaneous-endoscopic therapeutic ERCP which was used in 12 patients. The method provides an intact wire while maintaining all of the advantages of endoscopic visualization. METHOD
All patients with obstructive jaundice that had failed endoscopic cannulation or endoscopic placement of a wire because of papillary stenosis or biliary stricture underwent a standard percutaneous-transhepatic cholangiogram, performed by established techniques,"-13 and an external drain was placed to establish a tract. At the onset of the combined procedure, the obstructed bile duct was cannulated with a O.038-inch guide wire followed by the placement of a 6 F catheter transhepatically into the duodenum. At this point, an Olympus TJF-lO therapeutic ERCP instrument (Olympus Corporation, Lake Success, N.Y.) was passed into the duodenum. When the percutaneous catheter was identified at the ampulla of Vater, the transhepatic catheter was exchanged by standard technique for a wire basket stone retriever (Wilson-Cook Medical Inc., Winston-Salem, N.C.). The radiologist opened the basket within the duodenum, and a 400-cm-Iong, O.035-inch guide wire was placed through the endoscope into the open basket. While the endoscopist observed to ensure the absence of duodenal mucosal trauma, the basket was closed and withdrawn and the wire guide was pulled through the biliary tree and secured externally by the radiologist. If stone extraction was required, a wire-guided endoscopic sphincterotome (Wilson-Cook Medical, Inc.) was passed and sphincterotomy was performed to facilitate the removal of common bile duct stones. This was done with the wire guide left transhepatically in position, secured by a clamp held by the gloved hand of the radiologist. If an endoscopic stent was required, by standard endoscopic techniques,14.15 10 F Cotton-Leung prostheses (Wilson-Cook Medical, Inc.) were placed under endoscopic and fluoroscopic guidance. It was not necessary to perform a sphincterotomy to facilitate stent passage. The pusher tube was passed through the endoscope, and the proper position of the stent barb was confirmed by direct endoscopic visualization. When both the radiologist and the endoscopist were satisfied with the position of the stent, the radiologist released the guide wire, which was pulled back through the endoscope by the endoscopist. Removal of the pusher tube and endoscope completed the procedure.
RESULTS
From January 1987 through May 1989, 12 patients with endoscopically non-accessible biliary tract pa504
thology underwent combined percutaneous-endoscopic therapeutic biliary manipulation. All of the patients had refused surgery or were considered poor surgical risks. Ten of the patients underwent endoscopic biliary stent placement for malignancy and two for removal of common duct stones. The latter two patients each underwent sphincterotomy. One of these had undergone prior Billroth II gastrectomy. One patient developed a bile leak and perihepatic collection that required percutaneous drainage and eventual surgery. A second patient, who was considered a poor surgical risk with severe vascular insufficiency, short bowel syndrome, and multisystem failure, aspirated during the procedure and died 6 days later. The remaining 10 patients tolerated the procedure well without complication. DISCUSSION
The relative roles of the endoscopic versus the percutaneous approach to relieving obstructed biliary ducts remain open to discussion. The concern for complications such as pain, bile peritonitis, liver trauma, and bleeding associated with the placement of large bore catheters through the liver 16 has been offset somewhat by the generally easier accessibility of the percutaneous approach to the obstructed biliary tree. The technique of the combined approach as described by Tsang et al. 4 has been complicated by difficult assessment of stent positioning, resulting in placement of the stent beyond the ampulla of Vater, and has required the use of a percutaneous large bore pusher tube to reposition the stent. This has increased the risks associated with large catheter penetration of the liver. Another technique, described by Foutch et alY, by using a "push-pull" method resulted in excessive percutaneous manipulation and intraperitoneal bile leak. The technique described by Dowsett et al. 18 resulted in excessive torque and bending of the wire guide, making the procedure technically more difficult. The technique described in this report minimizes the need for percutaneous manipulation and lessens the risk of bile peritonitis. It allows direct visual confirmation of proper positioning of the stent at the ampulla of Vater and confirmation of bile flow. Furthermore, the use of the side-viewing instrument allows passage of various wire-guided sphincterotomes, baskets, dilators, and balloons, extending therapeutic capabilities to include stone retrieval in the most difficult cannulations. In the first 12 patients undergoing this procedure, there was a 100% success rate for relief of biliary obstruction. There were two patients who had major procedure-associated morbidity with one death. The first was a 38-year-old female with multi-system vascular disease who aspirated during the procedure in the face of severe vascular and pulmonary insuffiGASTROINTESTINAL ENDOSCOPY
ciency. She followed a progressive deteriorating course and died 6 days later. The other complication occurred when a polypoid ampullary tumor on a large stalk prevented direct endoscopic visualization of the ampullary orifice, and the stent was pushed too far into the bile duct. This required the use of 10 F pusher tube percutaneously to re-position the stent. Bile leakage and the subsequent need for surgical drainage resulted. More experience and further refinements will be required to continue to decrease the morbidity associated with the combined percutaneous transhepatic cholangiography-ERCP approach to obstructive jaundice. REFERENCES 1. Pereiras RV Jr, Rheingold OJ, Hutson D, et al. Relief of malignant obstructive jaundice by percutaneous insertion of a permanent prosthesis in the biliary tree. Ann Intern Med 1978;89:859-93. 2. Ring EJ, Oleaga JA, Freiman DB, Husted JW, Lunderquist A. Therapeutic application of catheter cholangiography. Radiology 1978;128:333-8. 3. Howels J, Lunderquist A, Inse I. Percutaneous transhepatic intubation of bile ducts for combined internal-external drainage in preoperative and palliative treatment of obstructive jaundice. Gastrointest Radiol 1978;3:23-6. 4. Tsang T, Crampton AR, Bernstein JR, Ramos SR, Weiland J. Percutaneous endoscopic biliary stent placement: a preliminary report. Ann Intern Med 1987;106:339-92. 5. Kerlan RK Jr, Ring EJ, Pogany AC, Jeffrey RB Jr. Biliary endoprosthesis: insertion using a combined peroral-transhepatic method. Radiology 1984;150:828-30. 6. Brambs HJ, Billmann P, Pausch J, Holstege A, lalm R. Nonsurgical biliary drainage: endoscopic conversion of a percuta-
7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
17. 18.
neous transhepatic into an endoprosthetic drain. Endoscopy 1986;18:52-4. Hatfield ARW, Murray RS, Lennard-Jones JE. Periampullary diverticula and common duct calculi-a combined transhepatic and endoscopic technique for difficult cases. Gut 1982;23:A889. Pass RB, Rankin RN. The transhepatic approach to a failed endoscopic sphincterotomy. Gastrointest Endosc 1986;32:221. Mason RR, Cotton PB. Combined duodenoscopic and transpapillary approach to stenosis of the papilla of Vater. Br J Radiol 1981;54:678. Shorvon PJ, Cotton PB, Mason RR, Siegel JH, Hatfield ARW. Percutaneous transhepatic assistance for duodenoscopic sphincterotomy. Gut 1985;26:1373-6. Muller PR, Harbin WP, Ferrucci JT Jr, Wittenberg J, VanSonnenberg E. Fine needle transhepatic cholangiography: reflection from 450 cases. AJR 1981;136:85-90. May GR, Bender CE, Williams HJR, MacCarthy RG. Percutaneous biliary decompression. Semin Intervent Radiol 1985;2:31-30. Cope C. Conversion from small (0.018 inch) to large (0.038 inch) guide wires in percutaneous drainage procedures. AJR 1982;138:170-1. Cotton PB. Duodenoscopic placement of biliary prosthesis to retrieve malignant obstructive jaundice. Br J Surg 1982;69:5013. Soehendra N, Reynders-Frederix V. Palliative duct drainage: a new endoscopic method of introducing a transpapillary drain. Endoscopy 1980;12:8-11. Dolley JS, Dick R, George P, Kirk RM, Hobbs KE, Sherlock S. Percutaneous transhepatic endoprosthesis for bile duct obstruction: complications and results. Gastroenterology 1984;86:9059. Foutch PG, Chinichian A, Talbert G, Sanowski RA. Endoscopic conversion of an external common bile duct stent. Gastrointest Endosc 1987;33:379-81. Dowsett JF, Vaira D, Hatfield ARW, et al. Endoscopic biliary therapy using combined percutaneous and endoscopic technique. Gastroenterology 1989;96:1180-6.
Case Re po rts Submucosal tumors of the terminal ileum managed by endoscopic polypectomy Takayuki Matsumoto, MD Mitsuo lida, MD Toshiyuki Matsui, MD Masahiko Hirakawa, MD Akiko Shiraishi, MD Takashi Yao, MD Masatoshi Fujishima, MD
Submucosal tumors of the terminal ileum are relatively rare. 1- 4 In contrast, submucosal tumors of the colon are increasingly reported, 5 probably because of the development of total colonoscopy. Herein, we report two cases of a submucosal tumor occurring in the From the Departments of Internal Medicine II and Pathology II, Faculty of Medicine, Kyushu University, Fukuoka, Japan. Reprint requests: Takayuki Matsumoto, MD, Second Department of Internal Medicine, Faculty of Medicine, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812, Japan. VOLUME 36, NO.5, 1990
terminal ileum-one being a lipoma, and the other a lymphangioma-both of which were managed by endoscopic polypectomy with a colonofiberscope. Case Reports Case 1
A 72-year-old Japanese man was admitted to our hospital for evaluation of vertigo in September 1985, and he was diagnosed as suffering from basilar insufficiency. During his hospitalization, barium enema was performed and a soft smooth polyp was noted in the ileocecal region (Fig. 1). He had no gastrointestinal tract symptoms. Physical examination and routine laboratory tests revealed no remarkable abnormalities. His fecal occult blood was negative. On abdominal CT examination, a structure with the density of fat tissue, measuring 3 X 2 em, was suspected in the ileocecal region. On total colonoscopy, a pedunculated bilobar yellowish red mass with a smooth surface prolapsed from the terminal ileum through the ileocecal valve after abdominal compression (Fig. 2). The 505
