Ampullary Carcinoma Associated With Removing Fractured Percutaneous Transhepatic Biliary Drainage Catheter for Hilar Cholangiocarcinoma

Abstract

Percutaneous transhepatic biliary drainage (PTBD) is an established method for decompression of biliary tract. Many complications related to PTBD have already been reported, however, spontaneous and complete fracture of PTBD catheter just after procedure is considered to be quite rare. We encountered a case, which PTBD catheter completely fractured on the next day of insertion for biliary obstuction due to hilar cholangiocarcinoma and advanced ampullary carcinoma was appeared at only ten months after removal of the fractured PTBD catheter. A 73-year-old man was diagnosed as hilar cholangiocarcinoma and PTBD was performed. PTBD catheter completely fractured on the next day of insertion. When the fractured PTBD catheter was endoscopically removed though papilla of Vater, there was no abnormality in both papilla of Vater and lower bile duct. Endoscopic biliary drainage was simultaneously performed. Consequently, he underwent extended right hepatectomy with resection of extrahepatic bile duct for Bismuth type IV hilar cholangiocarcinoma. Pathological examination of the resected specimen demonstrated that the tumor mainly composed of moderately differentiated adenocarcinoma and directly invaded to the hepatic parenchyma of the right lobe of the liver; therefore, the tumor was finally diagnosed to be stage IIA (pT3pN0M0) according to TNM classification. The distal stump of bile duct, which was transected at upper border of the pancreas, was pathologically confirmed to be free of cancer. At eight months after surgery, ampullary cacinoma was presented in the follow-up examination.Subtotal stomach-preserving pancreaticoduodenectomy was performed. Because pathological investigation revealed that the tumor was 4-cm in diameter and involved to both pancreas and duodenum, it was diagnosed as stage IIB (pT3pN1M0) according to TNM classification. The postoperative course was uneventful, however, he died of recurrence of ampullary carcinoma at fifteen months after the second operation in another hospital and an autopsy was not performed. We experienced a rare complication that was spontaneous and complete fracture of PTBD catheter on the next day of insertion. When the fractured PTBD catheter was removed by endoscopically, there were no abnormal findings in papilla of Vater and lower bile duct. Therefore, it was presumed that ampullary carcinoma was strongly associated with the removal of the fractured catheter through papilla of Vater. Endoscopic biliary drainage is recommended for decompression of malignant biliary obstruction.