An Alternative Modified Method of EUS-Guided Biliary Drainage in a Patient with Inoperable Cancer of Ampulla of Vater

對於不可開刀治癒的癌症所引起的膽管阻塞，目前的引流方式有手術引流、經皮穿肝引流及內視鏡引流；內視鏡引流具有風險較手術引流低、較經皮穿肝引流符合人體生理及較佳生活品質的優點；內視鏡引流通常採用ERCP方式置入膽管支架達到治療目的，然而，有少數案例因膽管阻塞嚴重或解剖結構變異而致無法完成膽管插入，此時可由EUS輔助，完成膽管插入及支架置入。我們報告一位54歲男性因十二指腸壺腹腺癌併肝臟轉移及黃疸，於接受經皮穿肝引流後，因每日膽汁引流量過多，造成脫水及營養不良而致影響後續化學治療及預後；爲解決此問題，遂實施內視鏡引流；執行內視鏡治療時，以ERCP無法進行膽管插入，遂改嘗試由經皮引流路徑進行導線置入，亦無法將導線置入十二指腸。於是改以EUS導引進行；治療時，EUS探頭因十二指腸變型而無法像多數國外已報告的案例般由球部作穿刺，在考慮尚有其它相伴治療效益下，改由十二指腸第二部份進行穿刺；爲了讓導線可往肝門方向延伸而達致理想的引流效果，穿刺的部位儘可能靠近膽管內阻塞部位之近肝門端，而此舉也確實使導線以小於90度的角度往肝門延伸；我們以部份有膜包覆之金屬支架置入膨脹的膽管，將幾乎所有尚未阻塞的遠端膽管支撐住，此金屬支架之開口朝食物在十二指腸內前進的方向，故而支架爲食物阻塞的機率推估上應比多數由球部進行穿刺的案例低。本案例於完成內視鏡引流後第四天，順利拔除經皮穿肝引流管，於三週後開始接受姑息性化學治療，追蹤9個月，沒有出現黃疸或膽道感染。

關鍵字

膽管阻塞；內視鏡引流；內視鏡超音波引導穿刺；部份有膜包覆之金屬支架

並列摘要

For a 54-year-old man with obstructive jaundice that was resulted from an inoperable cancer of Vater's ampulla, we established percutaneous transhepatic cholangeal drainage (PTCD) first and conducted endoscopic drainage for fears of mal-nutrition and dehydration. Endoscopic retrograde cholangiopancreatography (ERCP) failed in biliary cannulation and endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was performed. For difficulty in securing the scope in bulb due to luminal deformity and some expected following benefits, we advanced the scope into the second portion of duodenum and made a successful puncture into bile duct. A partially covered metal stent was inserted through the wall of second portion of duodenum into the bile duct. Such stent position was thought to avoid risks as sump syndrome or food occlusion, while most of the reported cases were managed with plastic stents through choledochogastrostomy or choledochoduodenostomy in the duodenal bulb. And a partially covered metal stent was thought to be with lower risk of migration. The patient discharged without a PTCD tube and started receiving palliative chemotherapy three weeks after the endoscopic treatment. We had learned from this case that EUS-CDS through the second portion of duodenum is feasible and may carry more benefits than that through the bulb or stomach, which was conducted in most previously reported cases.

並列關鍵字

biliary obstruction ； endoscopic drainage ； EUS guided puncture ； partially covered metal stent

國際替代計量

An Alternative Modified Method of EUS-Guided Biliary Drainage in a Patient with Inoperable Cancer of Ampulla of Vater

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