percutaneous transhepatic biliary drainage ( ptbd ) is an established nonsurgical procedure for the management of biliary obstruction , especially in patients in whom an endoscopic approach to the biliary system is impossible.1,2 compared with endoscopic biliary drainage , ptbd secures more stable drainage because it allows for serial monitoring of the quality and quantity of bile discharge .
duodenobiliary or jejunobiliary reflux of intestinal contents through a ptbd catheter , however , sometimes causes recurrent catheter obstruction or cholangitis .
here , we report a novel technique to prevent jejunobiliary reflux through a ptbd catheter : " antireflux ptbd 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/mm ( normal , 3,700 to 8,000/mm ) ; 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 ) ; -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 . after obtaining informed consent from the patient and her family members ,
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 )
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 . to 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 ) ( fig .
placement of a modified catheter over the prepositioned guidewire was achieved without any technical difficulties ( fig .
ultrasonography 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 .
although ptbd is an established procedure for biliary obstruction , clogging of a ptbd catheter by biliary sludge is inevitable .
it is believed that bacterial colonization in the biliary system ( bactibilia ) , which is usually seen after ptbd catheter placement , plays a major role in sludge formation , eventually leading to catheter obstruction.3 - 5 loss of papillary sphincter function after choledochojejunostomy , the location of the catheter tip in the intestine , and duodenal tumor invasion6 provoke the reflux of duodenal and jejunal contents into the biliary system as well as into the catheter , increasing the risk of catheter obstruction and cholangitis . in some cases , however , the catheter tip should be placed in the intestine in order to stabilize the catheter position or to dilate an anastomotic stricture .
frequent catheter irrigation with normal saline , larger diameter catheter placement , and periodical catheter exchanges have been attempted to prevent ptbd catheter obstruction .
our patient developed recurrent catheter obstruction in a short period of time despite the aforementioned attempts to decrease this complication .
we considered that in this patient , free reflux of intestinal contents into the catheter may have caused the unfavorable outcome . to prevent jejunobiliary reflux
this novel ptbd technique ( " antireflux ptbd " ) successfully prevented jejunobiliary reflux of intestinal contents in our patient based on the evidence of clearer bile discharge through the catheter and the disappearance of pneumobilia .
the advantage of this technique is its simplicity ; a commercially available ptbd catheter is easily modified using a nylon thread .
this technique , therefore , is applicable to clinical practice in many centers without technical difficulties or additional cost .
we consider that patients with increased intraluminal pressure ( e.g. , afferent loop obstruction ) are especially suitable candidates for antireflux ptbd because the enhanced jejunobiliary reflux is likely to provoke severe , life - threatening bacterial cholangitis.7,8 because a modified catheter is inserted in a fashion similar to that of a rapid exchange catheter , more technical difficulties may be encountered compared with the usual catheter exchange with a guidewire through the entire length of the catheter ( fig .
in addition , a guidewire must be passed through one of the proximal side holes of a modified catheter at the time of catheter exchange ( fig .
, however , these potential disadvantages were overcome without any technical difficulties . in conclusion ,
the antireflux ptbd technique is an effective procedure in select patients with recurrent ptbd catheter obstruction due to reflux of intestinal contents .
 percutaneous transhepatic biliary drainage ( ptbd ) is an established procedure for biliary obstruction . 
 however , duodenobiliary or jejunobiliary reflux of the intestinal contents through a ptbd catheter sometimes causes recurrent catheter obstruction or cholangitis . 
 a 64-year - old female patient with a history of choledochojejunostomy was referred to our department with acute cholangitis due to choledochojejunal anastomotic obstruction . 
 emergent ptbd was performed , but frequent obstructions of the catheter due to the reflux of intestinal contents complicated the post - ptbd course . 
 we therefore introduced a catheter with an antireflux mechanism to prevent jejunobiliary reflux . 
 a commercially available catheter was modified ; side holes were made at 1 cm and 5 to 10 cm ( 1 cm apart ) from the tip of the catheter , and the catheter was ligated with a nylon thread just proximal to the first side hole . using this novel " antireflux ptbd technique , " jejunobiliary reflux 
 was prevented successfully , resulting in a longer patency of the catheter . 
INTRODUCTION
CASE REPORT
DISCUSSION