View
214
Download
0
Category
Preview:
Citation preview
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 1/19
BILIARY-ENTERIC OBSTRUCFROM RECURRENT CANC
Resident(s): Osama Abdul-RahimAttending(s): Jeffrey Weinstein
Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA
Originally Posted:
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 2/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 3/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 4/19
DIAGNOSTIC WORKUP
Physical Exam Mild right upper quadrant tenderness to palpation
Laboratory Data Total Bilirubin: 7 mg / dL
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 5/19
DIAGNOSTIC WORKUP - IMAGING
Pancreatic adenocarcinoma
prior to Whipple
1 month s/p Whipple - No l
disease recurren
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 6/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 7/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 8/19
INTERVENTION
Left hepatic internal/external percutaneous
biliary drain was placed
3 days later, ductal dilatation
afferent jejunal limb rem
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 9/19
INTERVENTION
Transhepatic enterography shows persistent afferent
limb obstruction due to extrinsic compressionGuidewire was advanced
obstruction
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 10/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 11/19
CLINICAL FOLLOW UP
Follow up CT showed improvement in bothbiliary ductal and afferent jejunal limbdilatation after intervention
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 12/19
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?
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 13/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 14/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 15/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 16/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 17/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 18/19
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
8/21/2019 SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
http://slidepdf.com/reader/full/sir-rfs-case-series-biliary-enteric-obstruction-from-recurrent-cancer 19/19
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
Recommended