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).

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).

Suspected blockage of metallic stent in a patient with cholangiocarcinoma

This 65 year old patient had two metallic stents placed over the past 18 months. The first was an uncovered stent, followed 8 months later by a partially covered stent placed within the first one. He had now presented with raised bilirubin. The ultrasound scan showed multiple hepatic lesions with query between abscesses and metastatic lesions. The stent seemed patent on direct viewing (A: green arrow). A guidewire was maneuvered across the stent (B: green arrows marking the guidewire and red arrows show the previously placed metallic stent) followed by contrast injection which outlined a patent stent and normal calibre intrahepatic biliary channels (C1 & C2: green arrows). We flushed the stents with saline which removed some debris (D: green arrows show the patent stent and full washout of contrast). Our conclusion was that the raised bilirubin, coupled with patent stents and normal calibre intrahepatic biliary ducts, was attributable to the liver metastatic lesions.