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Biliary rendezvous or solo combined procedure for therapy of sump syndrome

1996; Elsevier BV; Volume: 43; Issue: 2 Linguagem: Inglês

10.1016/s0016-5107(06)80132-x

1097-6779

Bret T. Petersen,

Esophageal and GI Pathology

When free access to the distal common bile duct cannot be achieved for formal sphincterotomy, options include needle knife entry1Huibregtse K Katon RM Tytgat GNJ. Precut papillotomy via fine-needle knife papillotome: a safe and effective technique.Gastrointest Endosc. 1986; 32: 403-405Abstract Full Text PDF PubMed Scopus (167) Google Scholar or retrograde entry over a wire passed transhepatically in a so-called “combined procedure.”2Martin DF. Combined percutaneous and endoscopic procedures for bile duct obstruction.Gut. 1994; 35: 1011-1012Crossref PubMed Scopus (47) Google Scholar Similarly, Ghattas et al.3Ghattas G Deviere J Blancas JM Baize M Cremer M. Pancreatic rendez-vous.Gastrointest Endosc. 1992; 38: 590-594Abstract Full Text PDF PubMed Scopus (17) Google Scholar described entry to the minor papilla over a wire passed in a circular fashion up the ventral pancreatic duct and out the accessory duct to the duodenum. They term this the “pancreatic rendezvous procedure.” The following case describes use of a solo biliary rendezvous for performance of a biliary sphincterotomy in a case of sump syndrome. The patient, a 61-year-old man, underwent a cholecystectomy in November 1991 after recurrent bouts of pancreatitis. A concurrent choledochoduodenostomy was performed for proximal biliary dilation and distal narrowing presumed related to chronic pancreatitis. Immediately thereafter he developed daily postprandial epigastric aching pressure-pain radiating to his back. In October 1994 he sought further care for ongoing episodes. Studies included normal values for amylase, lipase, and liver enzymes and a CT scan demonstrating postoperative changes and pneumobilia. The patient's primary gastroenterologist questioned the occurrence of a sump syndrome in the distal common bile duct. Endoscopic cholangiography demonstrated a widely patent side-to-side choledochoduodenostomy in the apex of the duodenal bulb. The proximal biliary tree exhibited minimal supraduodenal narrowing, widespread intrabiliary air, and no obvious stones or strictures. The distal biliary segment was dilated and failed to drain via the major papilla. A short dilated cystic duct remnant was noted to insert low on the common bile duct ( Fig. 1 ). In the second portion of the duodenum there was a one cm diverticulum and no clearly visible papilla. Given the lack of easy access to the distal duct for standard sphincterotomy, we proceeded with antegrade wire and cannula access from the duodenal bulb, through the choledochoduodenostomy, down the distal duct, and out the papilla. Then, after advancing the scope to the papilla, where the exiting wire and cannula were identified ( Fig. 2 ), we passed a second cannula alongside the first through the therapeutic channel of the scope. Fig. 2Endoscopic view of wire and cannula passing superiorly toward bulb and reentering the duodenum toward the lens via the papilla. Second catheter is being positioned to advance over the former wire.View Large Image Figure ViewerDownload Hi-res image Download (PPT)This was used to cannulate the papilla in a retrograde fashion over the first antegrade wire—analogous to the normal trans-hepatic “combined” approach to the papilla (Fig. 3). Fig. 3Radiograph or abutting antegrade and retrograde cannulas over a single wire. Larger circle, Choledochoduodenostomy in duodenal bulb; smaller circle, level of papilla.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Thereafter, standard wire-guided sphincterotomy was easily performed, providing open drainage of the distal sump segment. No complications occurred and the patient has done well subsequently. After undergoing a side-to-side choledochoduodenostomy for improved biliary drainage, some patients develop a so-called sump syndrome. This refers to recurrent plugging of the distal intrapancreatic bile duct with vegetable material and biliary sludge leading to abdominal pain, occasional pancreatitis, or even proximal obstruction with cholangitis.4Baker AR Neoptolemos JP Carr-Locke DL Fossard DP. Sump syndrome following choledochoduodenostomy and its endoscopic treatment.Br J Surg. 1985; 72: 433-435Crossref PubMed Scopus (51) Google Scholar, 5Polydorou A Dowsett JF Vaira D Salmon PR Cotton PB Russell RCG. Endoscopic therapy of the sump syndrome.Endoscopy. 1989; 21: 126-130Crossref PubMed Scopus (14) Google Scholar Some degree of papillary narrowing might be expected to contribute to both poor drainage of this segment and difficulty with usual retrograde access. Needle knife entry is increasingly accepted when sphincterotomy is a planned therapeutic goal; however, its use requires significant experience and carries greater risk. Access over a wire passed through the papilla in an antegrade fashion is fairly easy and allows for performance of traditional sphincterotomy. In the setting of a proximal choledochoduodenostomy such antegrade wire access is essentially risk free and requires only some facility with passage of side-by-side wires through the scope. This is analogous to the “rendezvous procedure” for access to the minor papilla and the accessory duct. Another alternative for papillary access in this setting would be antegrade placement of a short (5 to 7 cm) stent through the choledochoduodenostomy and downward through the papilla to duodenum. This would allow for needle incision over the guiding stent or retrograde access through or alongside the stent, while foregoing the need for simultaneous antegrade and retrograde wires in the scope channel. Such an approach is especially helpful when the papilla and the biliary-enteric communication are distant from each other, as in endoscopic antegrade access to the papilla through a failing cholecystojejunostomy for subsequent retrograde stenting of the common bile duct. Awareness of varied means to the same end are often helpful for the endoscopist facing new or unexpected challenges. Hopefully these approaches will prove useful for those challenged by a sump syndrome with tough papillary access.