During wire manipulation in duct access procedures, conventional
endoscopic ultrasound (EUS) needles can shear their wire coating ([Fig. 1]), as has been previously well documented in
vascular procedures [1]
[2]
[3], thereby leaving a foreign body
in the duct and/or making it difficult to retract the wire into the needle. The
needle can also potentially cause trauma to the duct wall.
Fig. 1 Foreign body consisting
of a wire-coating in the bile duct (arrow).
The following two brief cases represent early examples of using a
novel blunt-ended access device ([Fig. 2]) that
contains a sharp needle-tipped stylet (Cook Medical, Winston Salem, North
Carolina, USA) to rescue failed biliary stenting.
Fig. 2 Dimpled (echogenic)
access metal sheath: a the needle-tipped sheath; and
b with the sharp stylet removed (Cook Medical).
The needle stylet is withdrawn after duct access has been obtained,
and wire exchange is then done through the blunt-ended metal sheath, which has
less potential for damaging the wire coating and the duct wall.
The first inpatient, an 84-year-old woman, had a circumferential
duodenal adenocarcinoma involving the entire second part of the duodenum (T4
due to pancreatic invasion). The ampulla was lost in tumor and the duodenal
lumen was too narrowed for a side-viewer; thus, a rendezvous procedure was
infeasible. A forward-viewing linear echoendoscope (Olympus America, Melville,
New York, USA) was used to visualize the upstream bile duct through the
duodenal bulb. A puncture was made with the device and the stylet was
withdrawn. With a 0.035-inch guide wire in the intrahepatic duct, a
10 × 60-mm, covered metal stent (Wallflex; Boston
Scientific, Natick, Massachusetts, USA) was inserted, after passage of a 7-Fr
stepdilator ([Video 1]). The patient was
discharged home feeling well the next day.
Video
1 This video demonstrates an
endoscopic ultrasound (EUS)-guided puncture of a dilated bile duct upstream
from an obstructing duodenal cancer, followed by dilation of the tract, and
placement of a covered metal stent across the choledochoduodenostomy.
The second patient was a 52-year-old man with jaundice due to tumor
progression after chemoradiotherapy for an inoperable tumor of the body of the
pancreas. Two attempts at conventional access by different physicians had
resulted in failure to get a wire through the stricture; as a result it seemed
unlikely that a rendezvous procedure would succeed. The same echoendoscope was
used to access the upstream duct through the bulb. The needle stylet was
withdrawn; a 7-Fr stepdilator was then passed over a wire, followed by a
covered 10 × 60-mm metal stent (Viabil; Gore, Flagstaff,
Arizona, USA) to drain the bile duct into the duodenum. Of note, the inner
catheter would not come back through the waist of the stent, which required
balloon dilation. The patient felt well the next morning and was
discharged.
In both cases the wire exchanges were smooth, without trauma or
stripping of the wire coating, arguably representing a major improvement over
the conventional needles in this regard. The needle puncture did not appear any
more difficult than with a traditional 19-G needle; echogenicity of the sheath
appeared excellent ([Video 1]). Care must be taken
to ensure the catheter tip, and not just the tip of the needle stylet, is in
the duct before the stylet is withdrawn. In addition, if the catheter were to
fall back out of the duct, it would not be possible to repuncture the bile duct
without reinserting the sharp stylet as the device tip is blunt. Although
foreign bodies are known to occur with conventional needles [3]
[4], their exact rate of formation
is unknown, as reporting has not been systematic. Rates may however be higher
following rendezvous procedures, which typically require more manipulation of
the wire for the stricture/papilla to be traversed.
Endoscopy_UCTN_Code_TTT_1AS_2AG
