I c t 6 r e s n 6 o p l a s i q u e s et e n d o p r o t h 6 s e s
Viddo-film d e 20 m n p a r J.-S. D E L M O T T E , J.-F. REY, R. C A S T R O R~alisation : A. S U E U R
Production : LABORATOIRES FOURNIER, DIJON
Jaundice during malignancy and endoprostheses
Ce film est consacr6 aux m6thodes d ' i n t u b a t i o n biliaire trans-tumorale per endoscopique :
-- les principes d ' u n e telle m 6 t h o d e de traitement d6riv6s de la loi de Poiseuille sont tout d ' a b o r d rappe- 16s expliquant la n6cessit6 d ' e m p l o i de proth6ses gros calibre donc ~ large d i a m & r e interne ;
- - la premi6re m 6 t h o d e de pose d6crite est celle qui n6cessite l'emploi d ' u n e n d o s c o p e ~t large canal ;
la seconde est celle qui utilise un guide fix6 dans les voies biliaires intra-h6patiques sur lequel coulisse une proth6se 6 large canal, l ' e n d o s c o p e 6tant pr6ala- blement retir6.
Diff6rents exemples de r6alisation sont ensuite fil- m , s .
Figure 3 Proth~se en place.
Figure 1 Cath~t~rieme r~trograde : st~nose du 1/3 moyen de la voie biliaire.
Figure 2
Mise en place du dispositif de montage : leader + catheter tdflonn~.
Critiques p a r J.-P. Capron, A m i e n s :
Le film de J.-S. Delmotte, R. Castro et J.-F. Rey, fort bien r6alis6 par A. Sueur, fait un point pr6cis et o b j e c t i f de la place des endoproth~ses biliaires dans le traitement palliatif des ict6res n6oplasiques. L a partie p r o p r e m e n t technique de la m6thode est largement d6taill6e et f o r t bien d o c u m e n t 6 e . Elle c o m p o r t e 3 phases successives : 1 ) l ' o p a c i f i c a t i o n r6trograde des voies biliaires, et n o t a m m e n t de la st6nose n6opla- sique, selon la technique habituelle ; 2) une sphinct6- r o t o m i e o d d i e n n e ; 3) la mise en place de la proth~se, grace ~t un endoscope A gros canal op6rateur, A un mat6riel de pose (cath6ter en t6flon et guide m6talli- que) n6cessaire au franchissement de la st6nose, et ~t un pousse proth~se.
L'utilisation d ' u n e proth6se de diam6tre interne large (2,4 A 2,6 mm) semble indispensable A un drai- nage satisfaisant de la bile ~t travers les orifices lat6- raux et distal. De petits ailerons lat6raux anti-descente et anti-remont6e maintiennent en place, ~t la mani~re de crochets, la proth6se au sein de la st6nose. La lon- gueur de la proth+se est, bien stir, choisie en fonction du si6ge de la st6nose.
Les indications de la m6thode sont ensuite pass6es en revue selon le si+ge de la t u m e u r . Les tumeurs des c a n a u x h6patiques droit et gauche, de la b i f u r c a t i o n et du canal h6patique c o m m u n , sont certainement les plus difficiles ~t proth~ser et repr6sentent la principale cause d'6chec. E n revanche, les succ~s sont fr6quents dans les st6noses des 1/3 m o y e n et inf6rieur de la voie biliaire principale (primitives ou secondaires ~t l'exten- sion d ' u n cancer de la v6sicule), dans les compressions dues ~t un cancer de la trite du pancr6as et dans les
A c t a E n d o s c o p i c a V o l u m e 1 7 - N " 2 - 1 9 8 7 105
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ampullomes vat6riens. Les auteurs concluent sur l'uti- lit6 de cette technique palliative qui permet de dia- gnostiquer et de traiter dans le m~me temps une affection incurable chirurgicalement. Elle semble rac- courcir le temps d'hospitalisation et permet une survie plus confortable.
I1 aurait 6t6 int6ressant que les auteurs rapportent leurs propres r6sultats, d6crivent les complications de la m6thode (angiocholite, 16sions duod6nales, obs- truction e t / o u fracture de la proth~se) et exposent les r6sultats d'&udes r6trospectives ou prospectives ayant compar6 cette technique, soit h l'abstention th6rapeu- tique pure et simple, soit ~ la mise en place d'endopro- th~se par voie percutan6e, soit ~t la d6rivation chirurgicale.
Notes des auteurs :
La derni~re remarque de J.-P. Capron concernant l'6tude de cette m6thode de traitement est tout h fait fond6e.
Cependant lors de la r6alisation pratique d'un film, il est souvent fastidieux de rapporter dans ce dernier des r6sultats d'6tudes chiffr6s ou non. Cela convient mieux h l'expos6 oral ou 6crit et la pr6sentation d'un film doit &re le pr6texte h une s6ance de discussion et de brefs expos6s compl6mentaires.
La description des complications, leur traitement, la comparaison 6ventuelle avec d'autres techniques palliatives de drainage biliaire fait l'objet d'un film en cours de r6alisation.
This film discusses endoscopic methods o f trans- tumoral biliary tract intubation :
- - principles governing such a method o f treatment derived f r o m Poiseuille's law are known as explaining the need to use large caliber prostheses which thus have a wide inner diameter ;
- - the first method o f installation requires use o f a large channel endoscope ;
- - the second is one which uses a guide fastened inside the hepatic biliary ductal system on which a large channel prosthesis slides, while the endoscope has been removed prior to this.
Different examples f o r performing this procedure were filmed.
Commentary by J.-P. Capron, Amiens :
The film by J.-S. Delmotte, R. Castro and J.-F.
Rey, and produced by the very competent A. Sueur gives an accurate and objective picture o f the value o f biliary endoprostheses in the palliative treatment o f jaundice arising as a result o f carcinoma.
The strictly technical aspect o f this procedure is abundantly detailed and well documented. It includes 3 successive steps : 1) retrograde opacification o f the biliary tract, and notably o f the stenosis caused by cancer, and performed using the usual method ; 2) s p h i n c t e r o t o m y o f the s p h i n c t e r o f Oddi ; 3) installation o f the prosthesis using an endoscope with a wide channel access, with instruments (a teflon catheter and metal guide) required to cross the steno- tic segment, and with a probe to insert the prosthesis.
Employment o f a wide inner-diameter prosthesis (2.4 to 2.6 mm) is absolutely essential f o r adequate bile drainage through the side and distal orifices. Small side flaps, acting as hooks, to prevent movement up or down hold the prosthesis in place within the steno- tic area. The length o f the stenosis, o f course, depends upon the site o f the stenosis.
Indications f o r this technique are then reviewed according to the anatomical site o f the tumor.
Tumors o f the right and left hepatic ducts, o f the common hepatic duct and o f its bifurcation are cer- tainly the most difficult types f o r prosthesis installa- tion and account f o r the main reason f o r failure o f this technique. On the other hand, successis fre- quently achieved when the stenosis is in the middle or lower l l 3 o f the common bile duct (initially arising or as a result o f dissemination o f cancer o f the gallblad- der), or when this method is chosen to relieve obstruc- tion caused by carcinoma o f the head o f the pancreas and in the treatment o f ampullary carcinoma. The authors o f this f i l m conclude by emphasizing the use- fulness o f this palliative method to diagnose and treat at the same time a disorder which is surgically incura- ble. It decreases the patient's hospital stay and impro- ves his quality o f life. It would have been interesting i f the authors had reported their own results, described complications arising with this method (cholangitis, lesions o f the duodenum, obstruction andnor fracture o f the prosthesis) and had presented results f r o m retrospective or prospective studies to compare the efficacy o f this technique, either by simply not trea- ting the patient, or by the percutaneous installation o f an endoprosthesis, or by a surgical shunt.
Authors' notes
The last comment made by J.-P. Capron concer- ning the investigation o f this method o f treatment is entirely wellfounded.
However, during the actual filming o f this proce- dure, it is often tedious to report study results with or without numerical values in the latter. This part o f the study may be more appropriately presented orally or in a written paper and a f i l m presentation should be the occasion f o r a discussion and short supplementary communications.
A description o f complications, their treatment, possible comparison to other palliative techniques f o r biliary drainage are the subject o f a f i l m currently beine oroduced.
106 Volume 17 N ~ 2 - 1987 Acta Endoscopica
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