Ahmad, Saba, MD

Hickey, Patrick, DO

Shah, Hiral, MD

Sullivan, Matthew, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineRecurrent Biliary Obstruction Overcome withMetal Biliary Stent Placement in the SurgicallyAltered Down Syndrome Patient for CongenitalDuodenal AtresiaPatrick Hickey DOLehigh Valley Health Network, Patrick.Hickey@lvhn.orgMatthew Sullivan DOLehigh Valley Health Network, Matthew.Sullivan@lvhn.orgSaba Ahmad MDLehigh Valley Health Network, Saba.Ahmad@lvhn.orgHiral Shah MDLehigh Valley Health Network, hiral_n.shah@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Gastroenterology Commons, and the Medical Sciences CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtHickey, P., Sullivan, M., Ahmad, S. & Shah, H. (2014, October, 17). Recurrent Biliary Obstruction Overcome with Metal Biliary StentPlacement in the Surgically Altered Down Syndrome Patient for Congenital Duodenal Atresia. Poster session presented at the AmericanCollege of Gastroenterology Annual Scientific Meeting, Philadelphia, PA.© 2014 Lehigh Valley Health Network References:1	 	Demirel	B,	Kekilli	M,	Sahin	B,	et	al.	ERCP	experience	in	patients	with	choledochoduodenostomy:	diagnostic	findings	and	therapeutic	management.	Surgical Endoscopy.	April	2011;25(4):1043-1047.2	 	Yamaner	S,	Bilsel	Y,	Sokucu	N,	et	al.	Endoscopic	diagnosis	and	management	of	complications	following	surgery	for	gallstones.	Surgical Endoscopy	[serial	online].	December	2002;16(12):1685-1690.Purpose•		Patients	with	Down	syndrome	have	increased	rates	of	GI	malformations	and	pathology•		In	our	case	a	patient	with	Down	syndrome	had	surgical	interventions	at	birth	for	congenital	duodenal	atresia	and	recurrent	cholelithiasis•		Duodenal	atresia	is	a	failure	of	the	duodenum	to	recanalize	in	gestation	resulting	in	gastric	outlet	obstruction	at	birth,	and	it	is	largely	associated	with	Down	syndrome•		It	requires	early	surgical	duodenoduodenostomy	or	duodenojejunostomy•		Patients	with	Down	syndrome	also	have	a	high	prevalence	of	cholelithiasis	which	may	require	surgery•		Historically,	surgical	procedures	like	choledochoduodenostomy	were	used	in	patients	with	variants	of	biliary	lithiasis•		We	describe	a	unique	endoscopic	intervention	in	an	adult	patient	with	Down	syndrome	with	recurrent	biliary	obstruction	and	convoluted	anatomy	after	childhood	surgeriesImagesDiscussion•		To	our	knowledge	this	is	the	first	case	of	an	endoscopic	intervention	in	altered	surgical	anatomy	for	duodenal	atresia	in	a	patient	with	Down	syndrome•		Gastroenterologists	should	become	familiar	with	congenital	GI	abnormalities	with	potential	surgical	alterations	to	prepare	for	interventions	in	these	patientsTranscutaneous catheter with a wire traversing internally through biliary anastamosis into the efferent limb, and a pediatric colonoscope is seen identifying the wire at the enteral anastomosisCase Presentation•		A	53	year-old	female	with	remote	choledochoduodenostomy	and	duodenojejunostomy	presents	with	recurrent	choledocholithiasis•		The	patient	has	a	history	of	Down	syndrome	with	duodenal	atresia	requiring	surgery	at	birth,	and	cholecystectomy	later	in	life•		She	had	recurrent	episodes	of	choledocholithiasis	requiring	percutaneous	transhepatic	cholangiography	by	interventional	radiology	(IR)  -  Interventions included balloon dilation of the ampulla and internal/external biliary tube placement•		She	still	continued	developing	stones	at	the	choledochoduodenostomy	anastomotic	site	with	abdominal	pain	and	elevated	transaminases•		Her	recurrent	tube	malposition	and	stone	formation	led	to	four	IR	procedures	for	tube	repositioning	and	stone	removal•		Endoscopic	intervention	was	necessitated	by	failed	IR	therapies	and	patient	discomfort	with	the	external	tube•		A	rendezvous	procedure	with	IR	was	initially	performed	to	define	positioning  -  The standard duodenoscope could not reach the anastomotic site and was exchanged for a pediatric colonoscope  - Antegrade cannulation with a wire via transhepatic access allowed retrograde guidance of the colonoscope to the anastomotic site•		A	subsequent	ERCP	was	performed	using	a	pediatric	colonoscope	based	on	previously	defined	anatomy  -  Cholangiogram, balloon sweeps with stone removal, and fully covered biliary metal stent deployment were performed•		In	this	case	deviation	from	the	standard	duodenoscope	used	in	ERCP	facilitated	the	definitive	therapy	in	a	patient	with	prior	choledochoduodenostomy•		At	follow-up	the	patient	is	doing	well	and	her	transaminases	have	normalizedA pediatric colonoscope directly visualizing the biliary enteric anastomosis after localization with transcutaneous wire guidanceCholangiogram showing significant dilatation of the bile duct (12 mm in cross-sectional diameter) with multiple stones appreciated in the distal common bile ductA fully covered self-expanding metal stent is directed into the biliary anastomosisA partially deployed biliary stent at the site of biliary anastomosisWell positioned biliary stent at the biliary anastomosis placed using a pediatric colonoscopeWire guided cannulation of the choledochoduodenostomy site using a pediatric colonoscopePlacement of a biliary stent at the anastomotic site using a pediatric colonoscopeBiliary metal stent after deployment at the biliary anastomosisLehigh Valley Health Network, Allentown, PARecurrent Biliary Obstruction Overcome with Metal Biliary Stent Placement in the Surgically Altered Down Syndrome Patient for Congenital Duodenal AtresiaPatrick Hickey DO, Matthew Sullivan DO, Saba Ahmad MD, Hiral Shah MD

Recurrent Biliary Obstruction Overcome with Metal Biliary Stent Placement in the Surgically Altered Down Syndrome Patient for Congenital Duodenal Atresia

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1487&context=medicine

Recurrent Biliary Obstruction Overcome with Metal Biliary Stent Placement in the Surgically Altered Down Syndrome Patient for Congenital Duodenal Atresia

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