Percutaneous transhepatic cholangiographic drainage (PTCD) catheters are the preferred
method of decompressing obstructed bile ducts if endoscopic transpapillary stent placement
is not possible. However, like transpapillary stents, transhepatic drainage catheters
occlude frequently and have to be exchanged at regular intervals. Exchanging PTCDs
poses a technical challenge to the gastroenterologist or radiologist.
We report here the case of a 70-year-old woman who had undergone a Whipple operation
for pancreatic cancer 1 year previously. She subsequently developed malignant obstructive
jaundice and, at another institution, had a PTCD placed from the external skin through
the bile duct, with a choledochoenterostomy into the jejunum (Yamakawa-type prosthesis).
She presented at our hospital with recurrent obstructive jaundice. The prosthesis
was found to be occluded, and an attempt was made to exchange it by passing a straight
guide wire through the prosthesis percutaneously. However, several attempts to pass
the guide wire were unsuccessful. During the procedure, the patient had an upper endoscopy
performed to locate the distal orifice of the prosthesis, in order to attempt retrograde
passage of the guide wire. It was possible to locate the stent orifice 30 cm distal
to the Billroth II anastomosis, but the guide wire could not be passed. The stent
was then grasped with a rat-tooth forceps, and the Yamakawa prosthesis was withdrawn
by gently pulling it from outside and advancing the forceps through the gastroscope
under fluoroscopic guidance (Figure [1]). Once the forceps appeared at the skin level, the new prosthesis was grasped and
the forceps was pulled back into the gastroscope. Correct positioning of the prosthesis
was verified by fluoroscopy and endoscopic visualization of free-flowing bile drainage.
The patient tolerated the procedure well and was discharged from the hospital the
next day.
This new method of exchanging PTCDs represents an alternative to the regular method,
which involves advancing a J-tipped guide wire through the prosthesis. The advantage
of the method described here is that a (usually expensive) straight guide wire does
not have to be bent into a J shape, rendering it useless for future endoscopic applications.
We would not currently recommend the method described here for routine care, but view
it as a second-line approach. It should not be attempted if the prosthesis has not
been in place for several weeks, since the tract may not have organized sufficiently
for the forceps to be passed.
Figure 1 Fluoroscopy during the procedure. a The Yamakawa prosthesis is grasped with the rat-tooth forceps. b The prosthesis is withdrawn halfway through the liver, with the forceps following
passively.
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