European Journal of Radiology.
12 ( 199 1) 1-3 1
Elsevier
EURRAD
00125
transgastric internal drainage, endoscopy and stenting of the pancreatic duct; a new technique
Percutaneous
J.C. Kurdziel, R.F. Dondelinger
and G. Barthelme
Department of Diagnostic and Interventional Radiology, Centre Hospitalier, Luxembourg
(Received
Key words: Pancreaticoscopy,
percutaneous;
2 July 1990; accepted
Pancreatic
endoprosthesis, percutaneous; radiology, pancreatic duct
Introduction Percutaneous opacitication of the pancreatic duct with ultrasound and computed tomography guidance [ 1,2] and percutaneous external ductal drainage [3] were described as alternatives to endoscopic cannulation when transpapillary access failed. We report the feasibility of percutaneous transgastric transpapillary drainage, percutaneous endoscopy and percutaneous stenting of the pancreatic duct. Case report A 73-year-old male without medical history, except extrasystoles, presented with upper abdominal pain, with recent exacerbation. The patient lost 7 kg of weight. Physical examination was normal. Serum creatinine was 1.60 mg%, serum amylase 137 U/l, CEA 4.84 U/ml, and CA 19.9 800 U/ml. Abdominal ultrasound examination showed a well defined hypoechoic 2-cm mass in the head of the pancreas, the distal pancreatic duct was dilated at 8 mm. Computed tomography of the upper abdomen confirmed enlargement of the anteroposterior diameter of the pancreatic head at 4.5 cm, body and tail of the pancreas were atrophic. The pancreatic duct was dilated at 8 mm. The pancreatic mass was hypodense and its margins unclear, the superior mesenteric vein was compressed by the mass. Three percutaneous pancreatic biopsies with a 1.2 mm cutting needle were negative. Coeliac, suAddress for reprints: R.F. Dondelinger, M.D., Department of Diagnostic and Interventional Radiology, Centre Hospitalier, 4 rue Barble, L-1210, Luxembourg. 0720-048X:91/$03.50
0 1991 Elsevier Science Publishers
after revision 28 September
Pancreatic
1990)
duct, catheter
drainage;
Interventional
perior mesenteric and left gastric arteriography was performed: the superior mesenteric vein was encased at the level of the pancreatic mass. The common hepatic artery was slightly displaced cephalad. Two 5 mm pseudoaneurysms of the gastroduodenal artery were present. Percutaneous biopsy of the pancreatic mass with angiography guidance was negative. ERC showed normal bile ducts, cannulation of the pancreatic duct failed. ERP was attempted twice, and failed despite of a sphincterotomy. A percutaneous diagnostic opacification of the pancreatic duct was planned. The dilated pancreatic duct was punctured after computed-tomography planning under fluoroscopic guidance with a 22G needle, by a transgastric approach. Opacification confirmed dilation of the pancreatic duct at the level of body and tail, and tumoral narrowing in the head. Anatomic distribution of the pancreatic ducts was normal. Percutaneous transgastric catheterization of the pancreatic duct was performed under local anesthesia and sedation, allowing further biopsies and pancreaticoscopy. The opaciIied pancreatic duct was punctured under fluoroscopic control with a F5 Teflon-sheathed needle at the level of the pancreatic body; a 0.035 torque-controlled guide wire was negotiated through the narrowed cephalic pancreatic duct and the papilla. A F8 biliary drainage catheter was placed percutaneously in the pancreatic duct, with the distal end in the duodenum and contrast medium was injected through the catheter (Fig. 1). The drainage catheter was exchanged for a 2.8 mm flexible endoscope (Surgitek, Racine, WI 53404) over a 0.035 guide wire after dilatation of the percutaneous and transgastric track with F9 semirigid dilators. Videopancreaticoscopy was recorded. At the cephalic level,
B.V. (Biomedical
Division)
Fig. 1. A F8 drainage catheter with sideholes was inserted percutaneously through the stomach in the pancreatic duct at the level of the body of the pancreas; the distal extremity of the catheter was located in the duodenum. Opacification confirmed stricture of the pancreatic duct in the head and post-obstructive dilatation in the body and tail. Fig. 2. Abdominal radiograph taken 3 days after percutaneous stenting of the pancreatic duct showed complete expansion of the expandable metal prosthesis (faintly visible) in the pancreatic head and good position of the F8 plastic prosthesis between the pancreatic duct and the stomach.
the mucosa of the pancreatic duct was hemorrhagic, without endoluminal tumor growth. Mural biopsy of the pancreatic duct was repeated, and was negative. A 4-cm-long expandable metal Wallstent prosthesis (Medinvent, Lausanne, Switzerland) with a diameter of 6 mm at full expansion was placed percutaneously in the pancreatic duct over a 0.035 guide wire. Duodenal protrusion of the prosthesis through the papilla was less than 5 mm, as confirmed by simultaneous transoral duodenoscopy. The pancreatic duct was inspected again after stent placement with the percutaneous endoscope. Perfect opening of the metal stent was confirmed. A pancreatic fistula at the puncture site was obviated by temporary percutaneous placement of a stent between the pancreatic duct and the stomach. A F8, 4-cm-long plastic prosthesis with sideholes was selected and inserted over the guide wire with a pusher. Neither gastric nor papillary bleeding was observed endoscopically after pulling out the endoscope from the stomach. The day after the procedure, clinical course of the patient was uneventful, leucocyte count was 10 300, serum amylase 181 UI/l, hemoglobine 11.8 g% and hematocrite 37.5%. Abdominal radiographs performed 3 days after the procedure showed complete opening of the expandable pancreatic metallic stent and good position of the gastropancreatic plastic stent (Fig. 2). The general condition of the patient deteriorated progressively over the following weeks although the patient could leave the hospital. Death from pancreatic cancer occurred 2 months after percutaneous pan-
creatic duct stenting without exacerbation pain during survival.
of abdominal
Discussion Among progress in therapeutic endoscopy, sphincterotomy of the pancreatic duct, nasopancreatic drainage or drug infusion, stone fragmentation and extraction, endoscopic inspection and stenting have evolved as alternatives to surgical procedures in the management of chronic pancreatitis [4-61 and malignant tumor of the papilla [ 71. Percutaneous access to the pancreatic duct represents an alternative to endoscopy when technical difficulties or inadequate anatomical con&ions prevent retrograde catheterization of the papilla. Percutaneous access to the pancreatic duct remained limited to diagnostic opacification in the literature [l-2], although percutaneous external drainage of the pancreatic duct was described in acute pancreatitis [ 31. A prerequisite for percutaneous puncture is sufficient dilatation of the pancreatic duct allowing its identification with ultrasonography or computed tomography. When the pancreatic duct is dilated more than 3 to 5 mm, percutaneous puncture is successful in 90% [ 11. A percutaneous transgastric approach is advisible, since a temporary prosthesis can be placed between the pancreatic duct and the stomach, obviating for a pancreatic leak after completion of a procedure and later endoscopic withdrawal of material. Computed tomography is particularly useful for planning the procedure:
the slice showing optimal contact between the pancreatic body and the posterior wall of the stomach should be selected for the percutaneous approach, as for internal gastric drainage of pancreatic pseudocysts [ 81. Coiling of the guide wire in the stomach during percutaneous catheterization of the pancreatic duct is avoided by the use of a stiff guide wire. Placement of a working sheath through the walls of the stomach facilitates insertion of a drainage catheter, a prosthesis or an endoscope. No particular difficulty was noticed in the reported patient during antegrade catheterization with the guide wire of the strictured pancreatic duct. Intraductal guide wire manipulation must be carried out carefully as the pancreatic duct shows multiple side branches and its wall is less resistent than the bile ducts. In the clinical case reported, transpapillary drainage, pancreaticoscopy and stenting of the pancreatic duct were performed by an exclusively percutaneous transgastric approach. The combined peroral-percutaneous technique commonly used in the biliary system [9], when endoscopic cannulation failed, can also be applied to the pancreatic duct, reducing the risk for pancreatic trauma. Potential complications of percutaneous transgastric puncture of the pancreatic duct are pneumoperitoneum, peritonitis, sepsis, pancreatitis, hemorrhage and vagal shock. Pancreatic bleeding and pancreatitis are minimized by a proper technique. Optimal cross-section localization of the dilated pancreatic duct reduces the number of attempts of percutaneous puncture. When the pancreas is atrophic, bleeding and pancreatitis are unlikely to occur during percutaneous puncture. Metallic expandable stents introduced percutaneously [lo] or endoscopically [ 1 l] in the biliary system can also be inserted in the strictured pancreatic duct, provided no intraluminal tumor growth is present, which could eventually proliferate through the meshwork of the prosthetic wall and lead to occlusion. The flexible metallic stents expand to 6 mm and more, but need a F7 introducer catheter. Standard plastic prostheses can be used as an alternative choice. In the same way, mini-endoscopes [ 121 in regular use for cholangioscopy, ureteroscopy and angioscopy pass through a F9 introducer sheath. Clinical indication for the procedure in the reported patient was confirmation of pancreatic malignancy and relief from pain by treating ductal obstruction. Intraductal biopsy remained negative despite of endoscopic aid, but abdominal pain was not exacerbated until the patient de-
ceased. Although diffusion of this technique will be limited, we advocate in the future the percutaneous transgastric approach to the pancreatic duct in chronic pancreatitis, when endoscopic treatment has failed. Percutaneous balloon dilatation of the pancreatic sphincter, antegrade sphincterotomy, intraductal mechanical, ultrasonic or laser lithotripsy are other techniques which can be performed by the percutaneous route, in the same setting. Failure of the percutaneous procedure can be related to a non-dilated pancreatic duct, inappropriate anatomical conditions which make a transgastric approach impossible, and failure of antegrade catheterization of the papilla. A drawback of the percutaneous approach is the difficulty of inspection or catheterization of the whole pancreatic duct. References 1 Ohto M, Karasawa E, Kimura K, Saisho H, Ono T, Okuda K, Tsuchiya Y. Ultrasonically guided percutaneous contrast medium injection and aspiration biopsy using a real-time puncture transducer. Radiology 1980; 136: 171-176. 2 Haaga JR, Highman LM, Cooperman AV, Owens FJ. Percutaneous CT-guided pancreatography and pseudocystography. AJR 1979; 132: 829-830. 3 Gobien RP, Stanley JH, Anderson MC, Vujic I. Percutaneous drainage of pancreatic duct for treating acute pancreatitis AJR 1983; 141: 795-796. 4 Takekoshi T, Maruyama M, Sugiyama N et al. Retrograde cholangiopancreaticoscopy (in Japanese). Gastroenterol. Endose. 1975; 17: 678. Cremer M, Toussaint J, Dunham F. Endoscopic management of chronic pancreatitis. Gastrointest. Endosc. 1980; 26: 65-69. Fuji T, Amano H, Harima K, Aibe T, Asagami K, Kinusaw K, Aryama S, Takemoto T. Pancreatic sphincterotomy and pancreatic endoprosthesis. Endoscopy 1985; 17: 69-72. 7 Huibregtse K, Tytgat GNJ. Carcinoma of the ampulla of Vater: the endoscopic approach. Endoscopy 1988; 20: 223-226. 8 Hancke S, Henriksen FW. Percutaneous pancreatic cystogastrostomy guided by ultrasound scanning and gastroscopy. Br. J. Surg. 1985; 72: 916-917. 9 Kerlan RK Jr, Ring EJ, Pogany AC, Jeffrey RB Jr. Biliary endoprostheses: insertion using a combined peroral-transhepatic method. Radiology 1984; 150: 828-830. stainless steel 10 Dick R. Gillams J, Dooley JS. Self-expandable braided endoprosthesis for biliary strictures. Radiology 1988: 169 (P): 25. II Neuhaus H, Hagenmuller F, Classen M. Self-expanding biliary stents: preliminary clinical experience Endoscopy 1989; 21: 225-228. 12 Foerster ECh, Schneider MU, Stommer P, Runge U, Domschke W. Miniscopes in gastroenterological endoscopy: inspection of the gallbladder and the biliary and pancreatic duct systems in autopsy specimens. Endoscopy 1988; 20: 316-320.
12 ( 199 1) 1-3 1
Elsevier
EURRAD
00125
transgastric internal drainage, endoscopy and stenting of the pancreatic duct; a new technique
Percutaneous
J.C. Kurdziel, R.F. Dondelinger
and G. Barthelme
Department of Diagnostic and Interventional Radiology, Centre Hospitalier, Luxembourg
(Received
Key words: Pancreaticoscopy,
percutaneous;
2 July 1990; accepted
Pancreatic
endoprosthesis, percutaneous; radiology, pancreatic duct
Introduction Percutaneous opacitication of the pancreatic duct with ultrasound and computed tomography guidance [ 1,2] and percutaneous external ductal drainage [3] were described as alternatives to endoscopic cannulation when transpapillary access failed. We report the feasibility of percutaneous transgastric transpapillary drainage, percutaneous endoscopy and percutaneous stenting of the pancreatic duct. Case report A 73-year-old male without medical history, except extrasystoles, presented with upper abdominal pain, with recent exacerbation. The patient lost 7 kg of weight. Physical examination was normal. Serum creatinine was 1.60 mg%, serum amylase 137 U/l, CEA 4.84 U/ml, and CA 19.9 800 U/ml. Abdominal ultrasound examination showed a well defined hypoechoic 2-cm mass in the head of the pancreas, the distal pancreatic duct was dilated at 8 mm. Computed tomography of the upper abdomen confirmed enlargement of the anteroposterior diameter of the pancreatic head at 4.5 cm, body and tail of the pancreas were atrophic. The pancreatic duct was dilated at 8 mm. The pancreatic mass was hypodense and its margins unclear, the superior mesenteric vein was compressed by the mass. Three percutaneous pancreatic biopsies with a 1.2 mm cutting needle were negative. Coeliac, suAddress for reprints: R.F. Dondelinger, M.D., Department of Diagnostic and Interventional Radiology, Centre Hospitalier, 4 rue Barble, L-1210, Luxembourg. 0720-048X:91/$03.50
0 1991 Elsevier Science Publishers
after revision 28 September
Pancreatic
1990)
duct, catheter
drainage;
Interventional
perior mesenteric and left gastric arteriography was performed: the superior mesenteric vein was encased at the level of the pancreatic mass. The common hepatic artery was slightly displaced cephalad. Two 5 mm pseudoaneurysms of the gastroduodenal artery were present. Percutaneous biopsy of the pancreatic mass with angiography guidance was negative. ERC showed normal bile ducts, cannulation of the pancreatic duct failed. ERP was attempted twice, and failed despite of a sphincterotomy. A percutaneous diagnostic opacification of the pancreatic duct was planned. The dilated pancreatic duct was punctured after computed-tomography planning under fluoroscopic guidance with a 22G needle, by a transgastric approach. Opacification confirmed dilation of the pancreatic duct at the level of body and tail, and tumoral narrowing in the head. Anatomic distribution of the pancreatic ducts was normal. Percutaneous transgastric catheterization of the pancreatic duct was performed under local anesthesia and sedation, allowing further biopsies and pancreaticoscopy. The opaciIied pancreatic duct was punctured under fluoroscopic control with a F5 Teflon-sheathed needle at the level of the pancreatic body; a 0.035 torque-controlled guide wire was negotiated through the narrowed cephalic pancreatic duct and the papilla. A F8 biliary drainage catheter was placed percutaneously in the pancreatic duct, with the distal end in the duodenum and contrast medium was injected through the catheter (Fig. 1). The drainage catheter was exchanged for a 2.8 mm flexible endoscope (Surgitek, Racine, WI 53404) over a 0.035 guide wire after dilatation of the percutaneous and transgastric track with F9 semirigid dilators. Videopancreaticoscopy was recorded. At the cephalic level,
B.V. (Biomedical
Division)
Fig. 1. A F8 drainage catheter with sideholes was inserted percutaneously through the stomach in the pancreatic duct at the level of the body of the pancreas; the distal extremity of the catheter was located in the duodenum. Opacification confirmed stricture of the pancreatic duct in the head and post-obstructive dilatation in the body and tail. Fig. 2. Abdominal radiograph taken 3 days after percutaneous stenting of the pancreatic duct showed complete expansion of the expandable metal prosthesis (faintly visible) in the pancreatic head and good position of the F8 plastic prosthesis between the pancreatic duct and the stomach.
the mucosa of the pancreatic duct was hemorrhagic, without endoluminal tumor growth. Mural biopsy of the pancreatic duct was repeated, and was negative. A 4-cm-long expandable metal Wallstent prosthesis (Medinvent, Lausanne, Switzerland) with a diameter of 6 mm at full expansion was placed percutaneously in the pancreatic duct over a 0.035 guide wire. Duodenal protrusion of the prosthesis through the papilla was less than 5 mm, as confirmed by simultaneous transoral duodenoscopy. The pancreatic duct was inspected again after stent placement with the percutaneous endoscope. Perfect opening of the metal stent was confirmed. A pancreatic fistula at the puncture site was obviated by temporary percutaneous placement of a stent between the pancreatic duct and the stomach. A F8, 4-cm-long plastic prosthesis with sideholes was selected and inserted over the guide wire with a pusher. Neither gastric nor papillary bleeding was observed endoscopically after pulling out the endoscope from the stomach. The day after the procedure, clinical course of the patient was uneventful, leucocyte count was 10 300, serum amylase 181 UI/l, hemoglobine 11.8 g% and hematocrite 37.5%. Abdominal radiographs performed 3 days after the procedure showed complete opening of the expandable pancreatic metallic stent and good position of the gastropancreatic plastic stent (Fig. 2). The general condition of the patient deteriorated progressively over the following weeks although the patient could leave the hospital. Death from pancreatic cancer occurred 2 months after percutaneous pan-
creatic duct stenting without exacerbation pain during survival.
of abdominal
Discussion Among progress in therapeutic endoscopy, sphincterotomy of the pancreatic duct, nasopancreatic drainage or drug infusion, stone fragmentation and extraction, endoscopic inspection and stenting have evolved as alternatives to surgical procedures in the management of chronic pancreatitis [4-61 and malignant tumor of the papilla [ 71. Percutaneous access to the pancreatic duct represents an alternative to endoscopy when technical difficulties or inadequate anatomical con&ions prevent retrograde catheterization of the papilla. Percutaneous access to the pancreatic duct remained limited to diagnostic opacification in the literature [l-2], although percutaneous external drainage of the pancreatic duct was described in acute pancreatitis [ 31. A prerequisite for percutaneous puncture is sufficient dilatation of the pancreatic duct allowing its identification with ultrasonography or computed tomography. When the pancreatic duct is dilated more than 3 to 5 mm, percutaneous puncture is successful in 90% [ 11. A percutaneous transgastric approach is advisible, since a temporary prosthesis can be placed between the pancreatic duct and the stomach, obviating for a pancreatic leak after completion of a procedure and later endoscopic withdrawal of material. Computed tomography is particularly useful for planning the procedure:
the slice showing optimal contact between the pancreatic body and the posterior wall of the stomach should be selected for the percutaneous approach, as for internal gastric drainage of pancreatic pseudocysts [ 81. Coiling of the guide wire in the stomach during percutaneous catheterization of the pancreatic duct is avoided by the use of a stiff guide wire. Placement of a working sheath through the walls of the stomach facilitates insertion of a drainage catheter, a prosthesis or an endoscope. No particular difficulty was noticed in the reported patient during antegrade catheterization with the guide wire of the strictured pancreatic duct. Intraductal guide wire manipulation must be carried out carefully as the pancreatic duct shows multiple side branches and its wall is less resistent than the bile ducts. In the clinical case reported, transpapillary drainage, pancreaticoscopy and stenting of the pancreatic duct were performed by an exclusively percutaneous transgastric approach. The combined peroral-percutaneous technique commonly used in the biliary system [9], when endoscopic cannulation failed, can also be applied to the pancreatic duct, reducing the risk for pancreatic trauma. Potential complications of percutaneous transgastric puncture of the pancreatic duct are pneumoperitoneum, peritonitis, sepsis, pancreatitis, hemorrhage and vagal shock. Pancreatic bleeding and pancreatitis are minimized by a proper technique. Optimal cross-section localization of the dilated pancreatic duct reduces the number of attempts of percutaneous puncture. When the pancreas is atrophic, bleeding and pancreatitis are unlikely to occur during percutaneous puncture. Metallic expandable stents introduced percutaneously [lo] or endoscopically [ 1 l] in the biliary system can also be inserted in the strictured pancreatic duct, provided no intraluminal tumor growth is present, which could eventually proliferate through the meshwork of the prosthetic wall and lead to occlusion. The flexible metallic stents expand to 6 mm and more, but need a F7 introducer catheter. Standard plastic prostheses can be used as an alternative choice. In the same way, mini-endoscopes [ 121 in regular use for cholangioscopy, ureteroscopy and angioscopy pass through a F9 introducer sheath. Clinical indication for the procedure in the reported patient was confirmation of pancreatic malignancy and relief from pain by treating ductal obstruction. Intraductal biopsy remained negative despite of endoscopic aid, but abdominal pain was not exacerbated until the patient de-
ceased. Although diffusion of this technique will be limited, we advocate in the future the percutaneous transgastric approach to the pancreatic duct in chronic pancreatitis, when endoscopic treatment has failed. Percutaneous balloon dilatation of the pancreatic sphincter, antegrade sphincterotomy, intraductal mechanical, ultrasonic or laser lithotripsy are other techniques which can be performed by the percutaneous route, in the same setting. Failure of the percutaneous procedure can be related to a non-dilated pancreatic duct, inappropriate anatomical conditions which make a transgastric approach impossible, and failure of antegrade catheterization of the papilla. A drawback of the percutaneous approach is the difficulty of inspection or catheterization of the whole pancreatic duct. References 1 Ohto M, Karasawa E, Kimura K, Saisho H, Ono T, Okuda K, Tsuchiya Y. Ultrasonically guided percutaneous contrast medium injection and aspiration biopsy using a real-time puncture transducer. Radiology 1980; 136: 171-176. 2 Haaga JR, Highman LM, Cooperman AV, Owens FJ. Percutaneous CT-guided pancreatography and pseudocystography. AJR 1979; 132: 829-830. 3 Gobien RP, Stanley JH, Anderson MC, Vujic I. Percutaneous drainage of pancreatic duct for treating acute pancreatitis AJR 1983; 141: 795-796. 4 Takekoshi T, Maruyama M, Sugiyama N et al. Retrograde cholangiopancreaticoscopy (in Japanese). Gastroenterol. Endose. 1975; 17: 678. Cremer M, Toussaint J, Dunham F. Endoscopic management of chronic pancreatitis. Gastrointest. Endosc. 1980; 26: 65-69. Fuji T, Amano H, Harima K, Aibe T, Asagami K, Kinusaw K, Aryama S, Takemoto T. Pancreatic sphincterotomy and pancreatic endoprosthesis. Endoscopy 1985; 17: 69-72. 7 Huibregtse K, Tytgat GNJ. Carcinoma of the ampulla of Vater: the endoscopic approach. Endoscopy 1988; 20: 223-226. 8 Hancke S, Henriksen FW. Percutaneous pancreatic cystogastrostomy guided by ultrasound scanning and gastroscopy. Br. J. Surg. 1985; 72: 916-917. 9 Kerlan RK Jr, Ring EJ, Pogany AC, Jeffrey RB Jr. Biliary endoprostheses: insertion using a combined peroral-transhepatic method. Radiology 1984; 150: 828-830. stainless steel 10 Dick R. Gillams J, Dooley JS. Self-expandable braided endoprosthesis for biliary strictures. Radiology 1988: 169 (P): 25. II Neuhaus H, Hagenmuller F, Classen M. Self-expanding biliary stents: preliminary clinical experience Endoscopy 1989; 21: 225-228. 12 Foerster ECh, Schneider MU, Stommer P, Runge U, Domschke W. Miniscopes in gastroenterological endoscopy: inspection of the gallbladder and the biliary and pancreatic duct systems in autopsy specimens. Endoscopy 1988; 20: 316-320.
