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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : TD01 - TD03 Full Version

Percutaneous Balloon Retrieval Technique for Fractured Biliary Drainage Catheter in a Paediatric Patient: Can a Major Surgery be Averted?


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52391.16113
Amrin Israrahmed, Somesh Singh, Rana Vishwadeep Mall, Rajanikant R Yadav

1. Senior Resident, Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 2. Senior Resident, Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 3. Senior Resident, Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 4. Additional Professor, Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Rajanikant R Yadav,
SGPGIMS Campus, Type IV MRA, Staff Residence, Lucknow, Uttar Pradesh, India.
E-mail: rajani24478@rediffmail.com

Abstract

Percutaneous Transhepatic Biliary Drainage (PTBD) involves temporary placement of an external drainage catheter into an obstructed bile duct prior to internal biliary stenting or surgery. Chronic indwelling PTBD catheters can develop surrounding adhesions and are prone to fractures and retention during their removal. Retained segments can cause impaired biliary drainage, inflammation and recurrent cholangitis. Retrieval of retained catheters can be done by endoscopic/surgical/percutaneous techniques. In patients who have undergone Hepatico-Jejunostomy (HJ), endoscopic removal is not possible and percutaneous/surgical removal are the only options. The authors present a case of a five-year-old child who came for removal of a fractured, retained PTBD catheter, nine months after undergoing HJ. The catheter was removed by a percutaneous balloon retrieval technique. The objective here is to highlight the technical challenges encountered and present a modification of the usual balloon retrieval technique used to successfully remove the catheter and thus avert a major surgery.

Keywords

Adhesions, Cholangitis, Hepatico-jejunostomy, Percutaneous transhepatic biliary drainage, Retained catheter

Case Report

A five-year-old male child presented to the department with complains of abdominal pain, fever and yellowish discolouration of skin for 15 days. Biochemical examination has been summarised in (Table/Fig 1), which revealed features of cholangitis. Abdominal ultrasound showed probe tenderness in the right upper quadrant with cystic dilatation of the Common Bile Duct (CBD) (Table/Fig 2)a. A subsequent Magnetic Resonance Cholangiopancreatography (MRCP) showed findings suggestive of a Type I choledochal cyst (Table/Fig 2)b-d. The patient was diagnosed to have choledochal cyst with cholangitis hence, an emergency segment V PTBD was done. A 10Fr Malecot catheter (Devon Innovations Pvt., Ltd., Bengaluru, Karnataka, India) was placed and adequate antibiotics (intravenous ceftriaxone 50 mg/kg/day for seven days) were given. The child underwent excision of choledochal cyst with Hepatico-Jejunostomy (HJ) after resolution of cholangitis. He developed postoperative cholangitis hence the PTBD catheter was not removed and he was started on antibiotics. After multidisciplinary discussion, the child was discharged with the catheter in situ with a plan to review after four weeks with percutaneous cholangiography (to assess HJ patency).

In view of Coronavirus Disease 2019 (COVID-19) pandemic, the patient missed his follow-up and presented nine months after discharge. Abdominal ultrasound showed no dilatation of intrahepatic biliary radicles and a percutaneous cholangiogram via the PTBD catheter showed patent HJ site with free flow of contrast, hence removal of PTBD catheter was planned. While removing the catheter under fluoroscopic guidance the catheter fractured, with nearly 4 cm of catheter within hepatic parenchyma, the tip of which was lying within the duct whereas the outer end was abutting the outer capsular margin of liver.

As one end of the catheter was within the biliary duct and the other end was abutting the hepatic capsule, there was a risk of biloma formation or biliary peritonitis. As the outer end of catheter was not visible externally, so we could not retrieve it with forceps but as the catheter tract had matured, it was re-cannulated using a hydrophilic guide wire of 150 cm (Radifocus, Terumo, Tokyo, Japan) which was secured across the HJ site (Table/Fig 3)a. A 10Fr sheath was introduced over the wire and tip of sheath was carefully approximated with the outer fractured end of catheter under fluoroscopic guidance (Table/Fig 3)b. A 5×40 mm balloon catheter (Mustang, Boston Scientific, Natick, MA, USA) was partially deployed such that the distal half of balloon (~20 mm) was within the fractured fragment and proximal half within sheath. The balloon was then partially inflated using a 1:1 ratio of water-soluble non ionic iodinated contrast agent (Lohexol {Omnipaque, 300 mg/mL}), GE Healthcare; Marlborough, United States) and normal saline (Table/Fig 3)c. This partially inflated balloon was slowly pulled out while keeping the sheath and catheter closely approximated to each other (Table/Fig 3)d. Thus, the team were able to retrieve the peripheral part of the fractured fragment outside the skin and the outer stem was then gripped with a metallic artery forceps and pulled to completely retrieve it (Table/Fig 4).

Repeat blood investigations revealed normalisation of TLC counts (6500/mm3), hence the child was discharged with follow-up advised at 3, 6, 12 months in first year and annually thereafter. The child has completed six months of follow-up and is doing well clinically. Written informed consent was obtained prior to performing the procedure. Waiver of consent was obtained from our Institutional Ethics Committee (IEC) in view of retrospective reporting of this case.

Discussion

Percutaneous Transhepatic Biliary Drainage (PTBD) is a minimally invasive technique of decompressing the biliary system (1). The primary aim is to prevent or ameliorate cholangitis (2). It is a temporary procedure until a more definitive treatment such as biliary stenting or surgery is established.

Prolonged indwelling catheters within the biliary system need regular exchange or flushing as they are prone to adhesions, fracture, obstruction, dislodgement and/or buckling (3),(4). The presurgery (prior to HJ surgery) laboratory investigations as summarised earlier were suggestive of cholangitis, hence PTBD was done in the present case (5). These catheters should not be left indwelling for a long time. The incidence of fracture increases in patients who are lost to follow-up. Fractured retained catheters are a challenge with respect to their removal. Some authors believe that the fractured segment may be left in situ if it is not causing any significant obstruction (4). However, these catheters can become a source of biliary obstruction, inflammation, stricture and/or recurrent cholangitis (1). Moreover, if the fractured segment does not lie entirely within the biliary system (as in the present case); they can cause biloma and liver abscesses (2). Additionally, in this case, the proximal tip of the catheter was abutting the hepatic capsule with a potential risk of biliary peritonitis.

The various options for retrieval of such fragments include: endoscopic, surgical and percutaneous approaches. Endoscopic retrieval comprises of cannulating the CBD via the ampulla and snaring out the fractured fragment within the biliary system. However, due to altered biliary anatomy (post HJ status) in this patient, this option was technically challenging. Also, as some PTBD catheters are rigid with sharp edges, there can be a risk of bowel obstruction, perforation, or fistula formation using the endoscopic approach (6). Surgical treatment would be more morbid and would be associated with increased hospital stay.

Few case reports of percutaneous retrieval have been described with the help of biopsy forceps, goose snare or balloon catheters (2),(7),(8),(9). As the fractured fragment was not seen at the skin surface, retrieving it by biopsy forceps was not feasible in the present case. Retrieval by balloon catheters or by goose snares require secure placement of a percutaneous sheath within the biliary system. Availability of appropriately sized goose snares is another concern. Balloon retrieval technique by conventional method requires, a secure placement of sheath within the biliary system, followed by balloon inflation central/distal to the fractured segment and then pulling the balloon back so as to displace the fractured segment proximally into the sheath (2),(4). The balloon can be introduced via the lumen of the fragmented catheter or via a wire parallel to the catheter. Once this is achieved, the fractured segment can be extracted or snared into the sheath (2). In the present case, the tip of the fractured segment was abutting the hepatic surface and hence placement of sheath securely within biliary system was not feasible. Hence, there was a modification in the balloon retrieval technique as described above. It is important to keep the ends of the sheath and the fractured fragment closely approximated during the entire retrieval process. Failure to do so would result in inflation of the balloon in the liver parenchyma with a potential of bilio-vascular or hepatic capsular injury.

Conclusion

Regular exchanges/flushing/repositioning of prolonged indwelling biliary catheters is essential to avoid complications like catheter blockage, fractures, adhesions and fibrosis. In patients with post HJ status removal of fractured catheters by endoscopy is technically challenging, hence percutaneous retrieval techniques are important. Balloon catheter assisted retrieval of retained fragment with modification of conventional technique can help avert a major surgery in these patients.

References

1.
Kwan JR, Low KSH, Lohan R, Shelat VG. Percutaneous transhepatic biliary drainage catheter fracture: A case report. Ann Hepatobiliary Pancreat Surg. 2018;22(3):282-86. [crossref] [PubMed]
2.
Hsien-Tzu L, Hsiuo Shan T, Nai Chi C, Yi Yang L, Yi You C, Chien An L. Percutaneous transhepatic techniques for retrieving fractured and intrahepatically dislodged percutaneous transhepatic biliary drainage catheters. Diagn Interv Radiol. 2017;23(6):461-64. [crossref] [PubMed]
3.
Venkatanarasimha N, Damodharan K, Gogna A, Leong S, Too CW, Patel A, et al. Diagnosis and management of complications from percutaneous biliary tract interventions. Radiographics. 2017;37(2):665-80. [crossref] [PubMed]
4.
Maher MM, Kealey S, McNamara A, O’Laoide R, Gibney RG, Malone DE. Management of visceral interventional radiology catheters: A troubleshooting guide for interventional radiologists. Radiographics 2002;22(2):305-22. [crossref] [PubMed]
5.
Food and Drug Administration. Investigations operations manual 2021 Appendix C. Blood serum chemistry-normal values https://www.fda.gov/media/75935/download.
6.
Namdar T, Raffel AM, Topp SA, Namdar L, Alldinger I, Schmitt M, et al. Complications and treatment of migrated biliary endoprostheses: A review of the literature. World J Gastroenterol. 2007;13:5397-99. [crossref] [PubMed]
7.
Gumus B. Percutaneous intervention strategies for the management of dysfunctioning biliary plastic endoprostheses in patients with malignant biliary obstruction. Diagn Interv Radiol. 2012;18:503-07. [crossref]
8.
Saad WE. Percutaneous transhepatic techniques for removal of endoscopically placed biliary plastic endoprostheses. Tech Vasc Interv Radiol. 2008;11:120-32. [crossref] [PubMed]
9.
Gupta M. Rare case of removal of intrabiliary retained broken PTBD wire with redo-hepaticojejunostomy. Int Surg J. 2019;6(3):1003-06. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/52391.16113

Date of Submission: Sep 13, 2021
Date of Peer Review: Dec 20, 2021
Date of Acceptance: Jan 19, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 14, 2021
• Manual Googling: Jan 18, 2022
• iThenticate Software: Feb 24, 2022 (6%)

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