PTCD-stent complex for recurrent malignant afferent loop obstruction after pancreaticoduodenectomy

Abstract

Background

Recurrent malignant afferent loop obstruction (ALO) after pancreaticoduodenectomy poses significant management challenges, with conventional interventions (stents, percutaneous transhepatic cholangio drainage [PTCD], or surgery) having substantial limitations.

Case presentation

A 78-year-old man with recurrent pancreatic cancer presented with jaundice, fever, and abdominal pain 7 months post-pancreaticoduodenectomy. Imaging confirmed malignant ALO with cholangitis (CA19-9: 6772 U/mL; bilirubin: 116.4 µmol/L).

Intervention

An innovative dual-pathway drainage technique was employed: (1) A flared self-expanding metal stent (SEMS) was deployed across the afferent loop stricture under CT guidance to restore luminal continuity; (2) A 10-Fr PTCD catheter was retained long-term, inserted through a stent mesh pore (≥ 4 mm), traversing the stent lumen with its tip positioned distally in the afferent loop (“PTCD-Stent Complex”).

Outcomes

Symptoms resolved within 48 h. Bilirubin normalized (33.3 µmol/L) and inflammatory markers improved by day 7. The catheter output stabilized at 150 mL/day, confirming balanced drainage. Follow-up at 3 months showed patent drainage and resolved dilatation. The patient resumed chemotherapy, avoided re-intervention for ALO, and maintained improved quality of life (GIQLI: 33→54) until death from systemic progression at 9 months.

Conclusion

The PTCD-Stent Complex provides effective dual-pathway drainage for malignant ALO, combining immediate decompression (PTCD) with sustained internal drainage (stent). Crucially, the catheter physically preserves a functional lumen despite tumor ingrowth, significantly prolonging patency. This minimally invasive approach is a promising option for high-risk surgical patients.

Introduction

Recurrent malignant afferent loop obstruction (ALO) after pancreaticoduodenectomy poses significant management challenges, with conventional interventions (percutaneous transhepatic cholangio drainage (PTCD) [1], endoscopic or percutaneous enteral stent placement (internal drainage) [2], or revisional surgery [3]) having substantial limitations. PTCD alone causes loss of bile and digestive dysfunction [4]; stents have a high rate of early re-occlusion (> 60% within 6 months) due to tumor ingrowth [5]; and surgery carries a high mortality risk (up to 15%) [6], particularly in this age group. In this report, we describe a novel “PTCD-Stent Complex” technique that aims to overcome these limitations by providing dual-pathway drainage and mechanically preserving luminal patency. An early version of this case report was previously posted as a preprint [7].

Case presentation

A 78-year-old man presented to the Pancreas Center with a 5-day history of progressive jaundice, fever, and abdominal pain. Seven months earlier, he had undergone a pancreaticoduodenectomy (Whipple procedure) for pancreatic head ductal adenocarcinoma. Postoperatively, he received adjuvant chemotherapy with the nab-paclitaxel plus gemcitabine (AG) regimen. His medical history was otherwise unremarkable.

On admission, physical examination revealed scleral icterus and mild epigastric tenderness. Laboratory studies were significant: leukocyte count: 12.1 × 10⁹ per liter (reference range, 3.5–9.5); neutrophil count: 10.2 × 10⁹ per liter; hemoglobin: 103 g per liter (130–175); platelet count: 81 × 10⁹ per liter (125–350); procalcitonin: 54.9 ng per milliliter (< 0.1); C-reactive protein: 96.6 mg per liter (< 5.0); carbohydrate antigen 19 − 9 (CA19-9): 6772 U per milliliter (< 37). Liver function tests showed: total bilirubin: 116.4 µmol per liter (5.1–19.0); direct bilirubin: 109.2 µmol per liter (0–6.8); alanine aminotransferase: 186.7 U per liter (9–50); aspartate aminotransferase: 198.2 U per liter (15–40); gamma-glutamyl transferase: 241.0 U per liter (10–60). Contrast-enhanced abdominal computed tomography (CT) revealed postoperative changes consistent with pancreaticoduodenectomy. There was marked dilatation of the afferent loop (Fig. 1A), as well as intrahepatic bile ducts and the pancreatic duct. Thickening at the pancreatojejunal and hepaticojejunal anastomoses was noted, raising concern for tumor recurrence causing afferent loop obstruction.

Fig. 1.

Radiologic Findings. Panel A (Admission CT) shows marked dilatation of the afferent loop (white arrow) suggestive of obstruction. Panel B (Procedure CT) shows the PTCD guidewire advanced into the dilated afferent loop, indicating incomplete intestinal obstruction. Panel C (Procedure CT) shows an enteral stent guidewire was then introduced via the upper gastrointestinal tract. Panel D (Procedure CT) shows a covered SEMS (WallFlex Duodenal Stent, Boston Scientific; chosen for its anchoring strength ≥ 1.5 N) was deployed to bridge the stricture over the wire, restoring luminal continuity. Panel E (Procedure CT) shows a deployed self-expanding metal stent (SEMS) within the afferent loop. The PTCD catheter is inserted through a side mesh pore (red arrow) within the stent and advanced further into the afferent loop distal to the stent. Panel F (3-Month Follow-up CT) shows the resolution of afferent loop dilatation

Given the diagnosis of recurrent malignant afferent loop obstruction with cholangitis, the goals were urgent decompression, restoration of biliary-enteric continuity, and delaying recurrent obstruction. We proposed an innovative combined approach: simultaneous placement of a self-expanding metal stent (SEMS) within the obstructed afferent loop and long-term retention of a PTCD catheter traversing the stent lumen, termed the “PTCD-Stent Complex”.

The placement process for the “PTCD-Stent Complex” was as follows: (1)PTCD Access and Guidewire Navigation: The right posterior hepatic duct was punctured under CT fluoroscopy. Pre-procedural CT angiography confirmed a safe trajectory that avoided the middle hepatic vein. A guidewire was advanced through the PTCD needle into the biliary tree. With careful dynamic contrast injection (small boluses administered approximately every 2 cm of guidewire advancement), the guidewire was navigated through the hepaticojejunostomy and advanced antegradely down the afferent loop. Given the postoperative, adhesed, and angulated anatomy, shaped catheters and torqueable hydrophilic guidewires were utilized. The guidewire successfully traversed the malignant stricture, confirming the presence of a lumen—albeit severely narrowed—rather than a complete obstruction (Fig. 1B). (2)Enteral Stent Placement: Once the afferent loop was confirmed to be patent, the PTCD catheter was withdrawn distal to the obstruction. An enteral stent guidewire was then introduced across the obstructive segment of afferent loop via the upper gastrointestinal tract (Fig. 1C). Over this wire, a covered SEMS (WallFlex Duodenal Stent, Boston Scientific; chosen for its anchoring strength ≥ 1.5 N) was deployed to bridge the stricture, restoring luminal continuity (Fig. 1D). (3)PTCD Catheter Placement: Retract the PTCD guidewire to the obstructed segment of the afferent loop, then the PTCD guidewire was advanced along the afferent loop toward the gastrointestinal anastomosis. During advancement, it passed through a side mesh pore (diameter ≥ 4 mm) of the previously deployed stent and was further advanced into the afferent loop between the obstructive segment and the anastomosis. A 10-Fr multi-sidehole PTCD catheter (with side holes both proximal and distal to the obstruction) was positioned so that its tip crossed the stent lumen and reached the afferent loop just proximal to the obstruction. This catheter traverses the obstructed segment, and its side-hole design ensures continued drainage of bile and pancreatic juice even in the event of future stent occlusion (Fig. 1E). The total procedure time was 55 min, with a CT fluoroscopy time of 18 min. No immediate complications (e.g., perforation, stent migration) occurred.

Postoperatively, the patient’s fever and abdominal pain resolved within 48 h. PTCD output stabilized at approximately 150 mL per day by day 3. A liquid diet was initiated and advanced to a regular diet by day 5 without issue. Laboratory parameters improved significantly by postoperative day 7: bilirubin normalized (total bilirubin 33.3 µmol/L), liver enzymes decreased substantially, and inflammatory markers (procalcitonin 0.24 ng/mL, CRP 28.1 mg/L) resolved. CA19-9 was 7421 U/mL. Chemotherapy was resumed at 2 weeks post-procedure.

Follow-up CT at 3 months confirmed the stent and PTCD catheter were patent and in position, with resolution of afferent loop and biliary dilatation (Fig. 1F). The patient’s quality of life, assessed by the Gastrointestinal Quality of Life Index (GIQLI), improved from 33 preoperatively to 54 at 3 months. He survived for 9 months after the procedure without experiencing complete afferent loop obstruction requiring re-intervention. He died ultimately from systemic disease progression.

Discussion

This case illustrates the successful application of a novel “PTCD-Stent Complex” technique for managing recurrent malignant afferent loop obstruction after pancreaticoduodenectomy, a challenging clinical scenario with limited effective options. Traditional interventions have significant drawbacks. Stent placement alone, while minimally invasive, is plagued by early tumor ingrowth/overgrowth leading to re-occlusion (median patency ~ 7.2 months, > 60% failure within 6 months). PTCD provides external drainage and controls infection but disrupts enterohepatic circulation, causing malabsorption and electrolyte imbalances, and requires long-term catheter management. Surgical bypass offers durable relief but carries prohibitive morbidity and mortality (up to 15%) in often frail, elderly patients with recurrent disease.

The PTCD-Stent Complex aims to synergize the benefits and mitigate the limitations of both approaches: (1)Internal drainage: The stent primarily restores physiological bile flow and enteral continuity. (2)External drainage backup: The PTCD catheter provides immediate decompression of infected bile and acts as a safeguard against cholangitis. Post-procedure output monitoring (target 100–200 mL/day) ensures adequate dual-pathway drainage; high output (> 300 ml/day) suggests internal drainage insufficiency needing catheter adjustment. (3)Physical patency preservation: Crucially, the PTCD catheter traversing the stent lumen creates a “tube-in-stent” structure. This physically occupies the stent’s cross-sectional area. Even with significant tumor ingrowth, this maintains a minimum functional lumen diameter (~ 3.3 mm for a 10-Fr catheter), significantly delaying time to complete obstruction. In this patient, it prevented complete occlusion for his remaining 9-month survival. (4)Minimally invasive & Repeatable: It avoids the trauma of re-laparotomy. If stent occlusion occurs, the existing PTCD tract potentially allows for repeat intervention.

Comparison with endoscopic approaches: Endoscopic approaches, including the use of short-type single-balloon enteroscopy to reach the afferent loop stenosis for direct stent placement, represent important advances in the management of ALO [8, 9]. Similarly, through the stent (rendezvous) techniques via a mature PTCD tract for biliary stricture management are established [10]. In the present case, a percutaneous approach was selected primarily due to the acute presentation with cholangitis and sepsis, where rapid biliary decompression via PTCD was the immediate priority. The percutaneous tract then provided a controlled, direct route to the afferent loop obstruction without the need for navigating postoperative upper GI anatomy endoscopically. Furthermore, the combined “PTCD-Stent Complex” technique, which requires the intentional passage of a catheter through the stent mesh, was conceptually and technically simpler to achieve from the established percutaneous access. The choice between percutaneous and endoscopic approaches should be individualized based on local expertise, patient anatomy, acuity of presentation, and the specific therapeutic goal.

The long-term co-existence of a plastic catheter within a metallic stent lumen raises valid concerns regarding catheter fatigue or shearing due to friction, exacerbated by physiological peristalsis and respiratory movement. Several factors in our approach likely mitigated this risk: (1) The catheter traversed the stent through a large side pore (≥ 4 mm) and lay relatively straight within the stent lumen, minimizing focal bending stress. (2) The afferent loop, post-pancreaticoduodenectomy, exhibits reduced peristaltic activity. (3) The external segment of the catheter was securely fixed to the skin with a dedicated locking device and a generous loop to absorb tension. While no fracture occurred during the 9-month follow-up, this remains a potential long-term complication. Regular follow-up imaging is essential to monitor catheter integrity. Future iterations of this technique could benefit from specially designed, reinforced catheters or integrated stent-catheter systems to enhance durability.

Managing a foreign body in a patient receiving immunosuppressive chemotherapy necessitates a rigorous infection control strategy [11]. Our protocol included: (1) Aseptic procedure: Strict sterile technique during placement and all subsequent catheter care [12]. (2) Prophylactic antibiotics: Intravenous broad-spectrum antibiotics (piperacillin-tazobactam) were administered during the procedure and post-procedure given the initial cholangitis [13]. (3) Standardized catheter care: Patients and caregivers were trained in daily exit-site care with chlorhexidine solution and secure, occlusive dressing changes. (4) Catheter patency maintenance: The catheter was flushed weekly with 10 mL of sterile saline to prevent sludge occlusion, which can be a nidus for infection [12]. (5) Education & Monitoring: The patient was instructed to monitor for signs of infection (fever, chills, discharge) and to report immediately [14]. We did not employ routine cyclic antibiotic prophylaxis (The use of antibiotics could interfere gut microbiota and reduce the effectiveness of chemotherapy [15]), opting instead for vigilant monitoring and prompt, targeted treatment of any suspected infection. The absence of catheter-related sepsis in this case supports the feasibility of this protocol, though it requires strict adherence.

The “PTCD-Stent Complex” likely provides a dual mechanism for maintaining drainage. First, the indwelling PTCD catheter serves as a guaranteed “safety valve” or backup external drainage route. If tumor ingrowth were to completely occlude the stent lumen, the catheter itself would maintain a decompressive pathway, preventing total obstruction and acute cholangitis. Second, we propose an additional, active “patency preservation” mechanism. The catheter, by occupying a central cross-sectional area within the stent (~ 3.3 mm diameter for a 10-Fr catheter), physically impedes the centripetal tumor ingrowth that typically leads to stent occlusion. It maintains a patent channel through the ingrowing tumor mass.

Furthermore, the side holes of the catheter (Fig. 1E) enable drainage of the afferent loop contents (even if the stent is occluded, bile and pancreatic juice in the obstructed segment can be drained externally). In this patient, follow-up CT at 3 months showed a patent stent lumen around the catheter, at the same time, the patient showed no symptoms such as jaundice or fever, suggesting the primary internal drainage was still functional. The stable, low-volume (150 mL/day) catheter output further indicated that most bile flow was internal, via the stent, with the catheter acting as a safeguard. Therefore, this composite can ensure continuous drainage during occlusion.

Key technical considerations for success include: (1)Guidewire Navigation: Overcoming post-surgical adhesions and tumor-induced angulation requires advanced techniques (e.g., catheter looping, reverse shaping, dual-wire) under meticulous dynamic contrast guidance (small boluses every 2 cm advancement) to prevent perforation. (2)Anatomical Precision: PTCD access must avoid major vasculature (CT angiography recommended). Stent placement must avoid covering the pancreaticojejunostomy to prevent pancreatitis. (3)Device Compatibility: Choosing a stent with sufficiently large side pores (> 4 mm for 10-Fr catheter passage) and strong radial force/flare design is critical. (4)Post-procedure Management: Monitoring PTCD output is essential to verify balanced dual-pathway function.

Limitations of this approach include its investigational nature in a single case, applicability primarily to malignant obstruction, and that it delays rather than cures obstruction. Future directions involve device refinement (e.g., pressure-sensing catheters, drug-eluting stents), earlier integration with systemic/local therapies (e.g., prompt chemotherapy post-stent, I-125 seed stents), and leveraging technology (3D printing, AI for complication prediction) for wider application.

Conclusion

The PTCD-Stent Complex represents a promising minimally invasive strategy for managing late recurrent malignant afferent loop obstruction after pancreaticoduodenectomy, particularly in high-risk surgical patients. It effectively provides immediate decompression, restores physiological drainage, and significantly prolongs stent patency by physically mitigating tumor ingrowth. Meticulous technique and careful patient selection are paramount. Larger studies are warranted to further validate its safety and efficacy.

Authors’ contributions

DXG and YM designed the research. DXG and JJT collected the data and performed the analysis. DXG, YM and JJT prepared the manuscript draft. DXG and JJT revised the manuscript draft. All the authors read and approved the final manuscript.

Funding

No.

Data availability

All the data and materials are presented in this manuscript.

Declarations

Ethics approval and consent to participate

This study was approved by the ethics committee of the Affiliated Hospital of Jiangsu University (Approval No. 20250125) in accordance with national regulations and the Helsinki Declaration.

And informed consent was obtained from the participant included in the study.

Consent for publication

Informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

The authors declare no competing interests.