Duodenal stenting following PTBS for periampullary tumor with gastric outlet obstruction

This 74 year old lady had previously undergone percutaneous transhepatic biliary stenting (PTBS) due to a metastatic periampullary tumor which had also infiltrated into the duodenum (A3 & B: white arrows) causing gastric outlet obstruction (don't forget to check for a succession splash in any patient with jaundice, kids). Once the biliary drainage had been taken care of, we moved to free the route out the stomach. The pyloric opening was narrowed and we dilated it using a TTS balloon (A1 &A2). Following this, we advanced our duodenal stent assembly across the bulb and descending duodenum (B & C1 : black arrows). The stent (20mm x 130mm) was then carefully unsheathed (C1 to C5: white arrows show the stent being deployed. Red arrows shows the "waist" forming right about the middle of the stent at the site of maximal luminal infiltration by the tumor).

Second time lucky-Managing metastatic peri-ampullary tumor with cholangitis

This 65 year old lady had been admitted with obstructive jaundice and cholangitis secondary to a metastatic peri-ampullary tumor. We encountered a swollen ampulla on duodenal intubation (A). Cannulation and contrast injection outlined a significantly dilated pancreatic duct (B: Black arrows) and what appeared to be the accessory duct (B: White arrow). We did a pancreatic papillotomy (C: White arrow). Further attempts here were unsuccessful and slight scope with-drawl showed an opening at the upper surface of the ampulla seen in image A (D: Black arrow), which was cannulated (E: Black arrow). This was the proper route as evidenced by wire cannulation (F: Black arrows). Contrast injection in this area outlined a dilated proximal bile duct and intrahepatic channels (G: White arrows) with no distal or mid duct delineation. A 10 mm diameter and 8 cm long partially uncovered metallic stent was prepped (I. We used a Micro-Tech stent. These come with an internal stiffening wire with a ring for removal prior to insertion: Red arrow). The stent assembly was placed across the strictured segment unto the dilated duct (J: Black arrows). The stent was then deployed (K1: The stent being deployed. Red arrow marks the gold reference mark which is kept visible just at the edge of field of view. K2: The deployed stent. A gush of contrast and white pus was seen. L1 & L2: White arrows show the fully deployed stent with black arrows indicating the proximal and distal radiographic markers).

Stenting a malignant duodenal stricture

This 70 year old gentleman had previously undergone placement of a metallic biliary stent last year for an ampullary tumor. He was subsequently lost to follow up and had only now presented with gastric outlet obstructive symptoms. A swallowed contrast study (A) clearly showed the problem. The previously placed stent was outlined (A: white arrows) along with the intrahepatic biliary channel (A: green arrows). The stricture was also seen as a thin structured segment in the second part of the duodenum (A: red arrow). On endoscopy, the affected area was seen with almost complete luminal obstruction (B: white arrow). We placed a biliary cannulation catheter across the stricture followed by contrast injection which outlined the extent of the stricture (C: red arrowheads) and the unaffected bowel segment beyond the stricture (C: blue arrow). The biliary stent was also seen (C: white arrowheads). A guidewire was then placed across the stricture (D: white arrows) followed by a stent assembly (E: black arrows). A 12 cm long stent of 20 mm diameter was then deployed (F1 & F2 : black arrows show the stent assembly. White arrowheads show the deployed portion of the stent . Red arrowheads show the distal  and middle radiographic markers of the stent. F3: Fully deployed stent. Stent outlined with white arrowheads. Red arrowheads showing the radiographic stent markers. Blue arrow showing the previously injected contrast in the lumen of the distal portion of the stent. G1 & G2: The stent as seen by the endoscope: white arrows. Compare with B).

Stage IV esophageal cancer with bronchoesophageal fistula

This 65 year old gentleman had been referred for palliative therapy for a stage IV esophageal cancer with a bronchoesophageal fistula communicating with the right main bronchus (CT chest.  A1: white arrow shows the extensive local invasion and white arrow in A2 shows the fistulous communication between esophagus and right bronchus). His barium studies didn't show any holdup of contrast but the irregular outline of the mucosa was evident (B1 & B2). On endoscopy, the lesion started at 23cm from incisors (C). The fistula opening was seen clearly (D: black arrow). The lesion continued till the  35cm mark (E) after which the lumen seemed disease free (F). Keep in in mid the 12cm long affected area, we decided to place a 14 cm long partially covered stent of 20mm diameter. This stent has a 1 cm uncovered segment at each end (G: Stent assembly partially deployed for demonstration - white arrow shows the sheath, black arrow shows the coated/covered segment of the stent and blue arrow shows the uncovered distal segment). After passing a guidewire, markers were stuck to the patient's body under fluoroscopic guidance to mark the extent of lesion (H: white arrows show the markers stuck on the patient's skin). The stent assembly was then placed in the correct position (I: white arrows) and deployed (J: white arrows show the lower end of stent being deployed and expanding. K: white arrows mark the fully deployed stent and black arrows indicate the skin markers). Repeat endoscopy after stent deployment showed that the upper end of the stent was barely above the upper margin of the tumor (L: white arrows). We decided to use a forceps to grasp the thread at the upper end to pull the stent slightly upward for a better clearer margin (M: white arrow). The stent was now in a better position to our satisfaction with a larger clear zone above the tumor (N: black arrows show the clear zone).

Gastric outlet obstruction secondary to duodenal ulcer induced stricture

This patient was a 65 year old lady who had developed duodenal luminal stenosis after healing of a large duodenal ulcer. On endoscopy, the duodenal lumen was reduced to a pinhole just beyond the bulb (A: white arrow). We were using an Olympus dual channel scope. We decided to use a straight ERCP cannula to try and go through the stricture (B) but even that couldn't go through. We were however able to get a guidewire across the stricture after engaging it with the cannula (C: white arrows). This was followed by dilatation of the strictured track with graduated dilatation catheters (D1, D2 & D3: white arrows). A stent assembly was then placed across the stricture (E: white arrows) and an uncovered self expanding metallic stent of 20mm diameter and 130mm length was deployed (F1 & F2: white arrows. Red arrows show the "waist" of the stent due to the strictured area. G1, G2 & G3: the stent going through expansion).