Hironori Tokumo, M.D., Ph.D. Kunio Ishida, M.D., Ph.D. Hironao Komatsu, M.D., Ph.D. Hideyuki Machino, M.D. Kenji Morinaka, M.D.

The Third Department of Internal Medicine, Hiroshima General Hospital, Hiroshima, Japan

Correspondence should be addressed to
Hironori Tokumo, M.D., Ph.D. The Third Department of Internal Medicine, Hiroshima General Hospital, 1-3-3, Jigozen, Hatsukaichi-city, Hiroshima 738, Japan
Tel:81-829-36-3111, Fax:81-829-36-5573

Percutaneous transhepatic biliary drainage (PTBD) is the last option for achieving biliary drainage for patients with nonresectable tumors obstructing the biliary tract. Although this external drainage technique relieves jaundice, its disadvantages include loss of biliary fluid and minerals, malabsorption of fat, and discomfort. To solve these problems, external biliary gastric drainage has been proposed. On the other hand, percutaneous endoscopic gastrostomy (PEG) is a useful method for providing nutritional support to patients unable to swallow (1). We have combined these two techniques, which can help patients improve their quality of life (QOL), and have named the resulting technique external biliary jejunal drainage with gastrostomy feeding (EBJD-GF). In this paper, we describe this procedure and report a case in which it was used.

Indications and Method
EBJD is indicated for patients with obstructive jaundice in whom PTBD has been performed following unsuccessful use of an internal drainage technique, e.g. metallic stenting. PEG is particularly useful for patients who require tube feeding or intravenous hyperalimentation (IVH). In these cases, the procedure described here should be adopted. A 20F NBR catheter (C.R.Bard, Inc.) is placed by PEG technique. Then a 9F jejunal catheter (C.R.Bard, Inc.) is passed through the NBR catheter, and the tip of the jejunal catheter is positioned in the jejunum. The lumen between the NBR catheter and the jejunal catheter opens into the stomach. Finally, the already placed PTBD catheter and the jejunal catheter are connected outside the patient's body. Originally, use of the combination of a 20F catheter and a 9F jejunal catheter had two purposes (2). One was to supply liquid food to the jejunum through the jejunal catheter, and the other was to decrease the intra-gastric pressure by suction through the lumen between the two catheters. In our procedure, each catheter is utilized differently. Externally drained bile from the PTBD catheter can flow back into the jejunum, and the opening between the NBR catheter and the jejunal catheter is utilized for tube feeding (Fig. 1).

Figure 1. Illustration of EBJD-GF
a) Externally drained bile from the PTBD catheter can flow back into the jejunum. b) The opening between the NBR catheter and the jejunal catheter is used for tube feeding.

Case report
An 83-year-old man with a history of subtotal gastrectomy due to gastric ulcer 20 years previously was referred to our hospital because of jaundice. X-ray CT revealed a malignant mucin-producing tumor in the head of his pancreas. An internal drainage catheter was placed through the tumor into the duodenum using a percutaneous transhepatic approach. The drainage catheter was accidentally dislocated, and massive bleeding into the intraperitoneal space from the liver occurred. Emergency suygery to stop bleeding was performed. At operation, it was judged that the tumor was too invasive to be resected. A PTBD catheter was placed again. Postoperatively, his per oral ingestion was poor enough that PEG was performed for supplementary tube feeding. Then EBJD-GF was performed. Although he had a history of subtotal gastrectomy and Billroth II reconstruction, PEG was successfully performed and a jejunal catheter was correctly placed, because guidance at the tip of the catheter could be used to lead the catheter itself. Since EBJD-GF, his nutritional status and daily living activities have improved.

Discussion
Several approaches to reinfuse drained bile into gastrointestinal tract has been tested (3-7). Our procedure is one of these, but has several additional merits. First, it permits the freedom from use of bags, e.g., PTBD bag and IVH supplying bag. This improves the patient's QOL. Second, considering of biliary flow, the patients can attain the same physiological condition of biliary flow as in normal enterohepatic circulation. Third, sufficient and safe nutritional support can be obtained with this procedure. A potential problem associated with this procedure is the presence of drainage catheters outside the patient's body. This means catheter management is required, which may be stressful for the patient. However, the extra-corporeal catheters may be advantageous. When trouble occurs in the drainage system, such as catheter occlusion, an extra-corporeal catheters can easily be changed. Since the external biliary gastric drainage originally proposed by Ponsky can cause bile gastritis (4), we decided for our procedure that externally drained bile should flow into the jejunum through a jejunal catheter. Another potential problem is backward flow of jejunal fluid into the biliary tract. However, bile flow in our case has continuously been forward; this is thought to be due to the pressure difference between the biliary tract and the jejunum (5). We conclude that the EBJD-GF procedure is useful for tube-fed patients with obstructive jaundice.

References
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2)Ponsky JL, Aszodi A. Percutaneous endoscopic jejunostomy. Am J Gastroenterol 1984; 79: 113-6.
3)Akiyama H, Nagusa Y, Saeki S, et al. A new method for internal biliary drainage in malignant obstructive jaundice: Intrahepatic cholangioenteric bypass via PTCD fistula. Acta Chir Scand Mar 1987; 153: 199-201.
4)Ponsky JL, Aszodi A. External biliary-gastric fistula: a simple method for recycling bile. Am J Gastroenterol 1982; 77: 939-40.
5)Shike M, Gardes H, Botet J, Coit D, Ciaburri D. External biliary duodenal drainage through a percutaneous endoscopic duodenostomy. Gastointest Endosc 1989; 35: 104-5.
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7)Ishizaki Y, Mitsusada M, Wakayama T. Percutaneous transhepatic biliary drainage combined with percutaneous endoscopic gastrostomy for internal biliary drainage. J Am Coll Surg 1994; 179: 738-40.