Percutaneous Transhepatic Biliary Drainage Using a Ligated Catheter for Recurrent Catheter Obstruction: Antireflux Technique
A 64-year-old female patient was referred to our department with a 1-day history of abdominal pain and fever. She had a history of choledochojejunostomy with Roux-en-Y reconstruction for common bile duct injury during laparoscopic cholecystectomy for cholecystolithiasis 2 years earlier. Laboratory data on admission were as follows: white blood cells, 13,900/mm3 (normal, 3,700 to 8,000/mm3); total bilirubin, 3.6 mg/dL (normal, 0.2 to 1.2 mg/dL); alkaline phosphatase, 868 IU/L (normal, 104 to 338 IU/L); γ-glutamyltranspeptidase, 320 IU/L (normal, 0 to 59 IU/L); and C-reactive protein, 6.12 mg/L (normal, 0.00 to 0.29 mg/dL). A contrast-enhanced computed tomography scan of the abdomen revealed marked dilatation of the bile duct of the left liver without evidence of bile duct stones or tumors. Based on these findings, a diagnosis of acute cholangitis due to biliary obstruction was made.\nAfter obtaining informed consent from the patient and her family members, emergent PTBD was performed under ultrasonographic and fluoroscopic guidance. The bile duct of segment three was punctured. A subsequent cholangiogram demonstrated a choledochojejunal anastomotic obstruction (). A 0.035-inch polymer-coated guidewire (Radifocus; Terumo Co., Tokyo, Japan) was passed successfully through the obstruction. At the end of the procedure, an 8-Fr balloon-tipped internal-external drainage catheter (Create Medic Co., Kanagawa, Japan) was placed across the choledochojejunal anastomosis to dilate the anastomotic stricture. We planned to change the catheter prophylactically until the anastomotic stricture resolved. Bile culture showed Escherichia coli and Enterobacter cloacae. Brushing cytology of the obstruction identified no malignant cells.\nAfter the initial PTBD, the patient recovered quickly and the acute cholangitis subsided. However, the occlusion of the PTBD catheter due to reflux of intestinal contents occurred repeatedly accompanied by elevated serum liver enzymes, requiring frequent cleaning of the catheter with flushing of natural saline to facilitate bile flow (nine times in 14 days). Larger-caliber (10-, 12-, and 16-Fr) catheters failed to prevent the reflux of intestinal contents into the catheter.\nTo circumvent the problem, we introduced a novel method using a modified PTBD catheter with an antireflux mechanism. We used a commercially available 10-Fr internal-external drainage catheter (Create Medic Co.), which originally had side holes 1 to 10 cm (1 cm apart) from the tip. We cut the distal side of this catheter and made side holes at 1 cm and 5 to 10 cm (1 cm apart) from the tip. Furthermore, the tip of the catheter was ligated with a nylon thread just proximal to the side hole (1 cm from the tip) () to prevent reflux. Placement of a modified catheter over the prepositioned guidewire was achieved without any technical difficulties ().\nUltrasonography performed 2 days after the procedure demonstrated the disappearance of pneumobilia, indicating successful prevention of the reflux of intestinal contents and air from the jejunum. Neither obstruction nor the discharge of intestinal contents through the catheter was observed until the prophylactic exchange of the catheter, 100 days after the procedure. At the time of removal of a modified catheter, we passed a guidewire through one of the proximal side holes without any technical difficulties.