賈中芝，田豐，王凱，蔣國民

·病例報告Case report·

胰腺癌導(dǎo)致的十二指腸梗阻經(jīng)肝放置營養(yǎng)管1例

賈中芝，田豐，王凱，蔣國民

晚期胰腺癌導(dǎo)致的膽道及十二指腸梗阻患者生存期一般較短，對此類患者應(yīng)以最小的創(chuàng)傷方法治療為主。本文報道1例晚期胰腺癌導(dǎo)致的膽道及十二指腸梗阻患者，膽道梗阻給予膽道支架治療后解除了梗阻性黃疸，由于此患者心臟功能不全不能耐受胃空腸吻合術(shù)，并且在DSA下和內(nèi)窺鏡下放置支架及營養(yǎng)管失敗，最后采取經(jīng)肝、膽道支架放置營養(yǎng)管治療，獲得了一定的療效。

胰腺癌，十二指腸梗阻，營養(yǎng)管

1　INTRODUCTION

Thesurvivalperiodofduodenalobstruction patients due to unresectable pancreatic cancer is only about 12 weeks［1］.However，in the setting of bothbiliary and duodenal obstruction，the survival period becomes further shorter［2］.Considering the systemic condition and poor prognosis，for such patients it is obligatory to employ minimally-invasive therapeutic scheme as far as possible.In the previous clinical practice，gastrojejunostomy［3］was regarded as the standard minimally-invasive treatment for malignant duodenal obstruction，but for recent years endoscopic duodenal stenting has been increasingly used topalliate duodenal obstruction［4］.However，the use of endoscopy is difficult in some cases because of the malignant duodenal obstruction.Therefore，feedingtube placement is an alternative for patient with duodenal obstruction when gastrojejunostomy or endoscopic duodenal stenting is unable to be performed.

This paperdescribes anovel techniquefor feeding tube placement in a patient with duodenal obstruction，in whom all gastrojejunostomy，endoscopic duodenal stenting and routine feeding tube placement failed to success.

2　CASE REPORT

ThisstudyisapprovedbyourInstitutional Review Committee，and the informed consent to publish is obtained from the patient.

The patient was a 61-year-old female，who presented at the first medical visit with jaundice and wasdiagnosedofobstructivejaundicedueto inoperable pancreatic cancer.She was admitted to hospital to receive biliary stent placement，and was uneventfulatthetimeofdischarge.Noother treatmentwasemployed.Onemonthlater，she developednauseaandvomiting，andendoscopic examination revealed duodenal obstruction，and the duodenal papilla was not affected.As her cardiac ejection fraction was only 19%，gastrojejunostomy was definitely not suitable for her.Even worse，both duodenalstentingandfeedingtubeplacement，performed under fluoroscopic or endoscopic guidance， failed to success.

Therefore，a new technique of percutaneous tube placement，which was performed via trans-hepatic and biliary route，was suggested.A commercially available percutaneous transhepatic cholangiodrainage（PTCD）set（Cook Medical，Cook，USA）was used. After puncturing the bile duct，a 0.038 inch guide wire was inserted until its tip entered the jejunum（fig.1）.Then，a 5-Fr sheath was introduced over the guide wire and a 5-Fr catheter（H1，Cook Co.Ltd.，Bloomington，USA）was advanced over the 0.038 inch guide wire until its tip was in the jejunum.The 0.038 inch guide wire was replaced by a long guide wire（150 cm in length；Radifocus Guide wire M Standard type，Terumo Co.Ltd.，Japan）.Then，the 5-Fr catheter and sheath were removed，and the tunnel was dilated by a dilator；and a 90 cm-long 7-Fr guiding catheter（Vista Brite Tip Guiding Catheter，Johnson&Johnson Co.Ltd.，Miami，F(xiàn)L，USA）was co-axially inserted with the 5-Fr H1 catheter until its tip was in the jejunum（fig.2）.Finally，both the guide wire and 5-Fr H1 catheter were removed（fig.3），and the 7-Fr guiding catheter outside of the body was fixed to the skin（fig.4）.After the procedure，the patient received routine care，prophylactic antibiotics and odynolysis.Every day a total of 2 000-2 400 ml liquid food was administered through the guiding catheter.The patient died of multiple organ failure 28 days after the procedure with nooccurrenceof hemobilia or infection.

圖1　

3　DISCUSSION

During its progression，the inoperable malignant pancreatictumornotonlycancausebiliary obstruction，but also can cause duodenal obstruction. Both biliary and duodenal obstruction will cause a series of obvious clinical symptoms，such as jaundice，nausea，vomiting，anorexia，weight loss，etc.，and the quality of life will be markedly impaired.As the patient is usually in a very poor condition and only a very short survival time can be expected，it must be kept in mind that for the treatment of such patient the minimally-invasive and effective palliation technique should be adopted as the first choice.Traditionally，bypass surgery or duodenal stenting is employed to relieve the clinical symptoms.Nevertheless，what can we do for these patients who cannot tolerate the bypasssurgeryandbothduodenalstentingand feeding tube placement，performed under fluoroscopic or endoscopic guidance，are unsuccessful in them. This is a question that has baffled the clinicians.The authorshaveextensivelyreviewedtherelevant medical literatures published in PubMed，and have designed a novel technique for feeding tube placement.

In this paper，the authors reported a novel technique for feeding tube placement in a duodenal obstruction patient.A 7-Fr guiding catheter is used as a feeding tube because its lumen is larger than the usual feeding tube.The 7-Fr guiding catheter is not veryflexible，buttheincidenceofitslumen obstruction is rare.The 7-Fr guiding catheter is placed into the upper jejunum in order to avoid the biliary tract infection due to food reflux.Through this 7-Fr guiding catheter 2 000-2 400 ml liquid food daily was successfully delivered into the patient's intestine for 28 days until the patient died of multiple organ failure，while no hemobilia or infection occurred.The results indicate that this technique of feeding tube placementforduodenalobstructionisclinically feasible.

In conclusion，although percutaneous placement of feeding tube via transhepatic route for duodenal obstructionduetopancreaticcancerisnota commonly used technique，the use of this technique should be seriously considered when the patient can not tolerate a bypass surgery，or when both duodenal stenting and feeding tube placement failed to success.

［1］Dormann A，Meisner S，Verin N，et al.Self-expanding metal stents for gastroduodenal malignancies:systematic review of their clinical effectiveness［J］.Endoscopy，2004，36:543-555.

［2］Mutignani M，Tringali A，Shah SG，et al.Combined endoscopic stent insertion in malignant biliary and duodenal obstruction［J］. Endoscopy，2007，39:440-447.

［3］Piesman M，Kozarek RA，Brandabur JJ，et al.Improved oral intake after palliative duodenal stenting for malignant obstruction:a prospective multicenter clinical trial［J］.Am J Gastroenterol，2009，104:2404-2411.

［4］Tonozuka R，Itoi T，Sofuni A，et al.Endoscopic double stenting for the treatment of malignant biliary and duodenal obstruction due to pancreatic cancer［J］.Dig Endosc，2013，25 Suppl 2:100-108.

Successful placement of nutrition tube via transhepatic route for duodenal obstruction due to pancreatic cancer：report of one case

JIA Zhong-zhi，TIAN Feng，WANG Kai，JIANG Guo-min.Department of Interventional Radiography，Second People's Hospital of Changzhou，Nanjing Medical University，Changzhou，Jiangsu Province 213003，China

JIANG Guo-min，E-mail：jgm916@163.com

Usually the survival period of patients with duodenal obstruction caused by inoperable advanced pancreatic cancer is rather short.For such patients，minimally invasive treatment should be employed as the first choice.This paper reported a case with advanced pancreatic cancer complicated by biliary and duodenal obstruction.After implantation of biliary stent，the obstructive jaundice was relieved. Because of the insufficient cardiac function，the patient was not able to tolerate gastrojejuostomy；besides，as both DSA-guided stent implantation and endoscopic nutrition tube placement failed to success，implantation of nutrition tube via the trans-hepatic and biliary route，as a novel tube placement technique，had to be carried out，and the result in this case was satisfactory.（J Intervent Radiol，2015，24：553-555）

pancreatic cancer；duodenal obstruction；nutrition tube

R735.8

D

1008-794X（2015）-06-0553-03

2014-09-13）

（本文編輯：顧偉中）

10.3969/j.issn.1008-794X.2015.06.022

江蘇常州南京醫(yī)科大學(xué)附屬常州市第二人民醫(yī)院介入血管科

蔣國民E-mail：jgm916@163.com