Cannulatome-aided selective intrahepatic bile duct cannulation

Abstract

To the Editor:Insertion of biliary endoprosthesis is now an established practice in palliating malignant obstructive jaundice in inoperable cases. Its use in benign conditions, such as in those with nonextractable bile duct stone and postcholecystectomy bile duct stricture, is also commonly performed as a temporary or definitive measure for relieving biliary obstruction. Hepatic bile duct strictures at or beyond the bifurcation sometimes create technical difficulties in the endoscopic approach. The problem commonly encountered in these situations is that the guide wire has the tendency to slip into the normal non-obstructed intrahepatic bile duct branches instead of the obstructed ones. Furthermore, there is a tendency for the cannula or the guide wire to enter the right hepatic duct preferentially, probably because of the natural curve albeit slight towards the right. Methods to overcome the problem include (1) the use of hydrophilic guide wires, (2) the use of steerable guide wires, (3) digitally grooming the tip of a standard Teflon wire, usually into a Z contour, (4) the Venu cannulating catheter made by Wilson-Cook, (Wilson-Cook Medical, Inc., Winston-Salem, N.C.), and (5) combined percutaneous and endoscopic approach. We have recently experienced good results in selectively cannulating the intrahepatic bile duct branches with the help of a commonly available tool, the cannulatome.Fig. 2The guide wire is shown being introduced into the right intrahepatic bile duct branch with the help of the bowed cannulatome in a patient with common hepatic duct stricture, recurrent cholangitis, and trahepatic gallstones.View Large Image Figure ViewerDownload (PPT)Obstruction of the right and left intrahepatic bile ducts is not an uncommon finding in patients with malignant disease affecting the liver, the bile duct, or the hilar lymph nodes. Complete decompression of the obstructed bile duct branches can be achieved by endoscopic means only on rare occasions unless an endoprosthesis can be inserted into both the right and the left intrahepatic ducts sequentially as demonstrated previously.1Neuhaus H Gottlieb K Classen M The “stent through wire mesh technique” for complicated biliary strictures.Gastrointest Endosc. 1993; 39: 553-556Abstract Full Text PDF PubMed Scopus (16) Google Scholar However, this often involves using the percutaneous approach, which is known to have increased morbidity and mortality.2Speer AG Cotton PB Russell RCG et al.Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice.Lancet. 1987; 2: 57-62Abstract PubMed Scopus (590) Google Scholar The endoscopic approach to selectively cannulate the obstructed bile duct branches is made difficult or sometimes impossible by the tendency of the guide wire to slip into the normal bile duct branches. Furthermore, there is a natural curve of the biliary system towards the right, making selective cannulation of the left hepatic duct more difficult. Methods mentioned above are valid alternatives but they either do not work or involve expensive instruments. The cannulatome is a multiple use item which is commonly stocked in endoscopy units that provide the ERCP service. Its maneuverability and ease of control in the angulation is superior to all other available accessories. The success in our cases illustrates the beauty of these advantages. Its use in similar difficult cases should be considered since it can significantly reduce the procedure time and attempts. Applications in larger series will be required to define its ultimate success rate. To the Editor:Insertion of biliary endoprosthesis is now an established practice in palliating malignant obstructive jaundice in inoperable cases. Its use in benign conditions, such as in those with nonextractable bile duct stone and postcholecystectomy bile duct stricture, is also commonly performed as a temporary or definitive measure for relieving biliary obstruction. Hepatic bile duct strictures at or beyond the bifurcation sometimes create technical difficulties in the endoscopic approach. The problem commonly encountered in these situations is that the guide wire has the tendency to slip into the normal non-obstructed intrahepatic bile duct branches instead of the obstructed ones. Furthermore, there is a tendency for the cannula or the guide wire to enter the right hepatic duct preferentially, probably because of the natural curve albeit slight towards the right. Methods to overcome the problem include (1) the use of hydrophilic guide wires, (2) the use of steerable guide wires, (3) digitally grooming the tip of a standard Teflon wire, usually into a Z contour, (4) the Venu cannulating catheter made by Wilson-Cook, (Wilson-Cook Medical, Inc., Winston-Salem, N.C.), and (5) combined percutaneous and endoscopic approach. We have recently experienced good results in selectively cannulating the intrahepatic bile duct branches with the help of a commonly available tool, the cannulatome.Obstruction of the right and left intrahepatic bile ducts is not an uncommon finding in patients with malignant disease affecting the liver, the bile duct, or the hilar lymph nodes. Complete decompression of the obstructed bile duct branches can be achieved by endoscopic means only on rare occasions unless an endoprosthesis can be inserted into both the right and the left intrahepatic ducts sequentially as demonstrated previously.1Neuhaus H Gottlieb K Classen M The “stent through wire mesh technique” for complicated biliary strictures.Gastrointest Endosc. 1993; 39: 553-556Abstract Full Text PDF PubMed Scopus (16) Google Scholar However, this often involves using the percutaneous approach, which is known to have increased morbidity and mortality.2Speer AG Cotton PB Russell RCG et al.Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice.Lancet. 1987; 2: 57-62Abstract PubMed Scopus (590) Google Scholar The endoscopic approach to selectively cannulate the obstructed bile duct branches is made difficult or sometimes impossible by the tendency of the guide wire to slip into the normal bile duct branches. Furthermore, there is a natural curve of the biliary system towards the right, making selective cannulation of the left hepatic duct more difficult. Methods mentioned above are valid alternatives but they either do not work or involve expensive instruments. The cannulatome is a multiple use item which is commonly stocked in endoscopy units that provide the ERCP service. Its maneuverability and ease of control in the angulation is superior to all other available accessories. The success in our cases illustrates the beauty of these advantages. Its use in similar difficult cases should be considered since it can significantly reduce the procedure time and attempts. Applications in larger series will be required to define its ultimate success rate. Insertion of biliary endoprosthesis is now an established practice in palliating malignant obstructive jaundice in inoperable cases. Its use in benign conditions, such as in those with nonextractable bile duct stone and postcholecystectomy bile duct stricture, is also commonly performed as a temporary or definitive measure for relieving biliary obstruction. Hepatic bile duct strictures at or beyond the bifurcation sometimes create technical difficulties in the endoscopic approach. The problem commonly encountered in these situations is that the guide wire has the tendency to slip into the normal non-obstructed intrahepatic bile duct branches instead of the obstructed ones. Furthermore, there is a tendency for the cannula or the guide wire to enter the right hepatic duct preferentially, probably because of the natural curve albeit slight towards the right. Methods to overcome the problem include (1) the use of hydrophilic guide wires, (2) the use of steerable guide wires, (3) digitally grooming the tip of a standard Teflon wire, usually into a Z contour, (4) the Venu cannulating catheter made by Wilson-Cook, (Wilson-Cook Medical, Inc., Winston-Salem, N.C.), and (5) combined percutaneous and endoscopic approach. We have recently experienced good results in selectively cannulating the intrahepatic bile duct branches with the help of a commonly available tool, the cannulatome. Obstruction of the right and left intrahepatic bile ducts is not an uncommon finding in patients with malignant disease affecting the liver, the bile duct, or the hilar lymph nodes. Complete decompression of the obstructed bile duct branches can be achieved by endoscopic means only on rare occasions unless an endoprosthesis can be inserted into both the right and the left intrahepatic ducts sequentially as demonstrated previously.1Neuhaus H Gottlieb K Classen M The “stent through wire mesh technique” for complicated biliary strictures.Gastrointest Endosc. 1993; 39: 553-556Abstract Full Text PDF PubMed Scopus (16) Google Scholar However, this often involves using the percutaneous approach, which is known to have increased morbidity and mortality.2Speer AG Cotton PB Russell RCG et al.Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice.Lancet. 1987; 2: 57-62Abstract PubMed Scopus (590) Google Scholar The endoscopic approach to selectively cannulate the obstructed bile duct branches is made difficult or sometimes impossible by the tendency of the guide wire to slip into the normal bile duct branches. Furthermore, there is a natural curve of the biliary system towards the right, making selective cannulation of the left hepatic duct more difficult. Methods mentioned above are valid alternatives but they either do not work or involve expensive instruments. The cannulatome is a multiple use item which is commonly stocked in endoscopy units that provide the ERCP service. Its maneuverability and ease of control in the angulation is superior to all other available accessories. The success in our cases illustrates the beauty of these advantages. Its use in similar difficult cases should be considered since it can significantly reduce the procedure time and attempts. Applications in larger series will be required to define its ultimate success rate.