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Abstract Biliary drainage for Perihilar Cholangiocarcinoma (PCCA) can be performed either by endoscopic retrograde cholangiopancreatography or Percutaneous Transhepatic Biliary Drainage (PTBD). To date there is no consensus about which method is preferred. Taking that into account, the aim of this study is to compare Endoscopic Biliary Drainage (EBD) versus percutaneous transhepatic biliary drainage in patients with perihilar cholangiocarcinoma through a systematic review and metanalysis. A comprehensive search of multiple electronic databases was performed. Evaluated outcomes included technical success, clinical success, post drainage complications (cholangitis, pancreatitis, bleeding, and major complications), crossover, hospital length stay, and seeding metastases. Data extracted from the studies were used to calculate Mean Differences (MD). Seventeen studies were included, with a total of 2284 patients (EBD = 1239, PTBD = 1045). Considering resectable PCCA, the PTBD group demonstrated lower rates of crossover (RD = 0.29; 95% CI 0.07-0.51; p = 0.009 I2 = 90%), post-drainage complications (RD = 0.20; 95% CI 0.06-0.33; p < 0.0001; I2 = 78%), and post-drainage pancreatitis (RD = 0.10; 95% CI 0.05-0.16; p < 0.0001; I2 = 64%). The EBD group presented reduced length of hospital stay (RD = -2.89; 95% CI -3.35 - -2,43; p < 0.00001; I2 = 42%). Considering palliative PCCA, the PTBD group demonstrated a higher clinical success (RD = -0.19; 95% CI -0.27 - -0.11; p < 0.00001; I2 = 0%) and less post-drainage cholangitis (RD = 0.08; 95% CI 0.01-0.15; p = 0.02; I2 = 48%) when compared to the EBD group. There was no statistical difference between the groups regarding: technical success, post-drainage bleeding, major post-drainage complications, and seeding metastases.
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Objective:To evaluate the effect of different options of preoperative biliary drainage (PBD) on perioperative complications of patients undergoing pancreaticoduodenectomy (PD).Methods:The clinical data of patients undergoing PD for periampullary carcinoma from January 2016 to November 2021 at Third Affiliated Hospital of Naval Medical University (Shanghai Eastern Hepatobiliary Surgery Hospital) were retrospectively analyzed. The 303 patients including 199 males and 104 females, aged (64.2±8.8) years. According to PBD, the patients were divided into two groups: percutaneous transhepatic biliary drainage (PTBD) group ( n=228) and endoscopic retrograde cholangiopancreatography (ERCP) group ( n=75). PBD operation-related complications (including bleeding, biliary leakage, etc.), postoperative complications of PD (including pancreatic fistula, biliary leakage, surgical site infection, etc.) and perioperative complications (PBD operation-related complications + postoperative complications of PD) were compared between the two groups. Univariate and multivariate logistic regression analysis were used to analyze factors influencing perioperative complications of PD. Results:The incidence of PBD operation-related complications in PTBD group was 10.1% (23/228), lower than that in ERCP group 25.3%(19/228), and the difference was statistically significant (χ 2=10.99, P=0.001). The incidence of postoperative complications of PD in PTBD group was 38.2%(87/228), lower than that in ERCP group 69.3%(52/75), the difference was statistically significant (χ 2=22.09, P<0.001). The incidence of total perioperative complications in PTBD group was 44.3% (101/228), lower than that in ERCP group 73.3%(55/75), the difference was statistically significant (χ 2=19.05, P<0.001). Multivariate logistic regression analysis showed that patients with periampullary carcinoma undergoing ERCP biliary drainage and PD had increased risk of surgical site infection ( OR=2.86, 95% CI: 1.59-5.16, P<0.001) and pancreatic fistula ( OR=3.06, 95% CI: 1.21-7.74, P=0.018). Conclusion:ERCP biliary drainage is a risk factor for postoperative pancreatic fistula and surgical site infection in patients with periampullary carcinoma undergoing PD. PTBD should be recommended as the first choice for the patients underwent PD.
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Objective:To evaluate the clinical efficacy of PTCD and ERCP combined with T tube in the perioperative period of biliary anastomosis in patients with moderate to severe obstructive jaundice.Methods:The data of 93 patients with moderate obstructive jaundice who met the inclusion criteria and planned to undergo cholangiojejunostomy (including reconstruction after pancreaticoduodenectomy) in Shuguang Hospital Affiliated to Shanghai University of traditional Chinese medicine from March 2015 to December 2021 were collected. According to the perioperative drainage strategy, 54 cases were divided into PTCD group and 39 cases were divided into ERCP combined with intraoperative T-tube drainage group. Retrospective cohort method was used to analyze the bile duct diameter, postoperative hospital stay, operation cost, time of jaundice reduction, degree of jaundice reduction, average postoperative bile loss, postoperative bile leakage, abdominal infection of the two groups. The measurement data were expressed as mean ± standard deviation( ± s), and t test was used for comparison between groups. The data of skewed distribution were represented by M( Q1, Q3), and nonparametric rank sum test was used. Chi-square test was used for counting data. Results:The preoperative yellowing reduction time, operation cost, mean bile loss 7 days after operation, time to remove biliary drainage tube, and postoperative hospital stay in PTCD group were (5.9±3.1) d, (59 846.3±9 129.7) yuan, 210.0(170.0, 325.0) mL/d, (18.4±5.6) d, and(10.7±4.4) d, respectively, while those in ERCP group were (9.5±4.4) d, (77 833.1±12 164.5) yuan, 285.0(225.0, 370.0) mL/d, (41.4±17.2) d and(15.3±5.6) d, respectively. The difference between the two groups was statistically significant ( P<0.05). There was no significant difference between the two groups in general condition before drainage, cholangitis and hemorrhage after drainage, degree of jaundice reduction, bile leakage after surgery, abdominal infection, etc. Conclusions:When performing biliary enterostomy in patients with moderate or above obstructive jaundice, PTCD and ERCP combined with intraoperative T-tube drainage are effective means to improve the safety of perioperative period. PTCD has some advantages in reducing jaundice efficiency, operation cost and rapid postoperative rehabilitation.
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Malignant biliary obstruction (MBO) leads to obstructive jaundice as a result of bile excretion disorder, which may cause complications such as cholangitis, sepsis, hepatic failure and even life-threatening. Biliary drainage is an effective mean to relieve symptoms and improve patients'quality of life. At present, endoscopic retrograde cholangiopancreatography (ERCP) is the first-line palliative treatment for MBO patients without surgical opportunity. In recent years, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been gradually accepted as an alternative to percutaneous transhepatic biliary drainage (PTBD) in MBO with failed ERCP. The available evidence suggests that EUS-BD might even replace ERCP as the first-line procedure in patients with malignant distal biliary obstruction by experienced surgeons. This paper reviews the research progresses of EUS-BD in MBO.
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Background: Percutaneous Transhepatic Biliary Drainage (PTBD) is performed either via right or left-ductal approach, on the basis of status of primary confluence, secondary confluence and atrophy of liver parenchyma. Our study compares the complications of two approaches in malignant obstruction. The objectives of this study was to assess and compare complications of PTBD.Methods: This study was a prospective hospital based study performed for a period of 2 years from 2016 to 2018.PTBD was performed either via right in 16 patients or left-ductal approach in 15 patients, on the basis of status of primary biliary confluence and atrophy of liver parenchyma.Results: Both minor and major complications were more common in right-sided approach as compared to left-sided approach with most common major and minor complication being cholangitis (16.12%) and fever (12.9%) respectively.Conclusions: PTBD is an excellent palliative procedure to drain the bile ducts in malignant obstruction. Although complications of PTBD are more common in right sided approach but results are statistically insignificant.
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Objective To evaluate the feasibility and safety of guidewire guidance method in percutaneous transhepatic biliary drainage (PTBD). Methods A total of 174 consecutive patients with biliary diseases who underwent PTBD in Heilongjiang Provincial Hospital from January 2011 to December 2017 were enrolled in this retrospective study. There were 85 patients undergoing conventional PTBD ( the conventional group), and 89 wire-guided PTBD (the wire-guided group). In the wire-guided group, the contrast media was not injected immediately after puncture, on the contrary, the needle coat was inserted deeply along the bile duct thereafter, then the bile was extracted to reduce the pressure of bile duct, at last the contrast media was infused. The drainage success rate and incidence of cholangitis related with PTBD were compared between the two groups. Results The incidence of PTBD-related cholangitis of the wire-guided group was significantly lower compared with the conventional group [ 10. 1％ ( 9/89 ) VS 21. 2％( 18/85) ,χ2=5. 270, P=0. 022] , although the drainage success rate was not significantly different between the two groups [ 94. 4％ ( 84/89) VS 97. 6％ ( 83/85) ,χ2=1. 200, P=0. 273] . Conclusion Wire-guided PTBD may yield a similar success rate, but can reduce the incidence of cholangitis compared with conventional PTBD.
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Objective To observe the efficacy of percutaneous transhepatic biliary drainage (PTBD) combined with transarterial chemoembolization (TACE) in treatment of malignant obstructive jaundice, and to evaluate its application value in clinic. Methods A total of 82 patients with malignant obstructive jaundice who received PTBD from January 2017 to January 2019 in Taiyuan Central Hospital were collected. The patients were divided into the experimental group who received TACE (41 cases) and the control group who could not receive TACE (41 cases) after PTBD. Clinical symptoms, liver function, tumor markers, drainage tube patency rate and survival time of the two groups were compared before and after the treatment. T-test and chi-square test were used for statistical analysis, and Kaplan-Meier method was used for survival analysis. Results A total of 93 drainage tubes were placed in 82 patients, and 109 TACE treatments were performed in the experimental group. PTBD and TACE both had successful results. After PTBD, 72 patients felt jaundiceand obvious alleviation of other clinical symptoms. There were no serious complications after PTBD and TACE. Postoperative follow-up results showed that compared with the total bilirubin (TBIL) [(269±113)μmol/L], the direct bilirubin (DBIL) [(159 ±74) μmol/L], alanine transaminase (ALT) [(118 ±40) U/L] and aspartate aminotransferase (AST) [(111±55) U/L] before the operation, the TBIL [(46±11)μmol/L], DBIL [(28±10)μmol/L], ALT [(35±12) U/L] and AST [(33±12) U/L] in the experimental group were decreased significantly 3 months after the operation, and the differences were statistically significant (all P<0.05). TBIL [(48±9)μmol/L], DBIL [(25±10) μmol/L], ALT [(32±9) U/L] and AST [(30±12) U/L] in the control group were decreased significantly compared with TBIL [(291±114)μmol/L, DBIL [(171±66)μmol/L], ALT [(129±54) U/L] and AST [(114±43) U/L] before the operation, and the differences were statistically significant (all P< 0.05). There was no significant difference in liver function between the two groups before the operation and 3 months after the operation (both P>0.05). The level of carbohydrate antigen-199 in the experimental group at 6 months after PTBD was lower than that in the control group [(426 ±136) U/ml vs. (569 ±204) U/ml; t = 19.457, P < 0.05]. There were statistical differences in the patency rate of the both groups at 6, 9 and 12 months after PTBD (all P< 0.05). The median survival time in the experimental group was longer than that in the control group (310.4 d vs. 234.5 d; χ2= 12.678, P< 0.05). Conclusion The effect of PTBD in patients with malignant obstructive jaundice is obvious. The combination with TACE after PTBD can prolong the survival of patients and it is worthy of clinical application.
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Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, we encountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admitted with type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using a percutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected after the procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treated conservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-up tubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic procedures in patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should be careful to avoid misdiagnosing this condition as intestinal perforation.
Subject(s)
Aged, 80 and over , Humans , Bile , Drainage , Follow-Up Studies , Gastrointestinal Tract , Intestinal Perforation , Intestine, Small , Pneumoperitoneum , Stents , Urinary Bladder NeoplasmsABSTRACT
OBJECTIVE: To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). MATERIALS AND METHODS: From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. RESULTS: A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186−237 days) and 141 days (95% CI, 126−156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. CONCLUSION: Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.
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Humans , Male , Cholangiocarcinoma , Cholangitis , Cholecystitis , Drainage , Fistula , Hemobilia , Jaundice, Obstructive , Klatskin Tumor , Lost to Follow-Up , Peritonitis , Retrospective Studies , Sewage , Stents , Survival RateABSTRACT
Objective To systematically review the effectiveness and safety of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) for preoperative biliary drainage in patients with Klatskin Tumors.Methods The Pubmed,Embase,Web of Science,CNKI,VIP and WanFang Data from January 1998 to December 2017 were searched for published studies which compared endoscopic biliary drainage (EBD) with percutaneous transhepatic biliary drainage (PTBD) for preoperative biliary drainage.A Meta-analysis was then performed using the Revman 5.3 software.Results Seven cohort studies were included.There were 366 patients in the PTBD group,and 400 patients in the EBD groups.When compared with EBD,PTBD was associated with a lower risk of cholangitis (OR=0.31,95％ CI 0.20～0.48,P＜0.05),a lower risk of pancreatitis (OR=0.11,95％ CI 0.04 ～ 0.34,P＜0.05),and a lower risk of overall complications (OR=0.48,95％ CI 0.30 ～ 0.77,P=0.002).The rate of conversion from one procedure to the other was significantly lower in the PTBD group than the EBD group.The initial technical success rate and postoperative morbidity and mortality rates were similar in the 2 groups.Conclusion In patients with Klatskin tumors who require PBD,PTBD is a better initial biliary drainage method with lower incidences of procedure-related cholangitis,pancreatitis overall complications and conversion to other drainage procedures.
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Objective To analyze the clinical value of percutaneous transhepatic biliary drainage (PTBD) in the treatment of obstructive jaundice.Methods A total of 479 patients with obstructive jaundice were enrolled in PLA General Hospital from July 2015 to July 2017 underwent percutaneous transhepatic biliary drainage,the preoperative serum total bilirubin was 92 ～ 614 μmol/L,the target bile duct was 2 ～ 16 mm in diameter.The PTBD was ultrasound guided.Results All of the 479 patients underwent PTBD successfully,and 99.6％ showed evident alleviation of jaundice postoperatively.Conclusions Ultrasoundguided PTBD is an effective method for reducing jaundice for preoperative or palliative treatment in patients with obstructive jaundice.The method of operation is worthy of further study.
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Preoperative biliary drainage (PBD) is an important part of preoperative management of patients with hilar cholangiocarcinoma which could reduce serum total bilirubin,remove jaundice,improve liver function,and reduce the mortality and morbidity.Although PBD is widely used in biliary surgery now,there are still several controversial issues in clinical applications about the indication of PBD,the best way of PBD,implantation metastasis of PBD and so on.With the development of medical image and surgical technology,we had a better understanding of PBD now.This review summarizes the recent scenario and current advancement about the above-mentioned controversy.
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Objective To determine the impact and the risk factors of different methods of preoperative biliary drainage (PBD) for malignant obstruction jaundice (MOJ) on overall survival (OS).Methods Databases including the PubMed,Medline,Web of Knowledge,and other databases were searched up to 30th April,2018 for clinical studies which compared the OS rates between percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD) for MOJ.Hazard ratio (HR) and Odds Ratio (OR) with 95％ confidence interval (CI) were performed using the Review Manager 5.3 software to synthesize the results.Results Nine studies were enrolled in this meta-analysis,which included 818 patients in the PTBD group and 1253 patients in the EBD group.EBD was shown to be superior to PTBD in OS (HR=0.63,95％ CI:0.51～0.77,P＜0.05).Risk factors analysis showed that patients in the EBD group had a higher rate of early tumor stage (P＜0.05) and a lower rate of lymphatic metastasis (P＜0.05).When compared with the PTBD group,the EBD group had a lower rate of intraoperative bleeding (P＜0.05),and a higher rate of adjuvant therapy (P＜0.05).Conclusion In PBD for patients with resectable MOJ,there was insufficient evidence to support EBD to be superior to PTBD in OS.
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Objective To select the best preoperative biliary drainage (PBD) method for patients with hilar cholangiocarcinoma.Methods The PubMed,EMBASE,Web of Science,CNKI,and Wanfang Database were systematically searched for prospective or retrospective studies on biliary drainage for patients with hilar cholangiocarcinoma with obstructive jaundice.The drainage-related cholangitis,pancreatitis,hemorrhage,and the success rate in relieving jaundice were analyzed.The meta-analysis was performed using the Review Manager 5.3 and the stata 12.0 using a fixed or random effects model.Results This meta-analysis included 12 studies with 1567 patients.The results showed a lower risk of cholangitis with PTBD than EBD (RR=0.60,95％CI:0.39～0.95,P＜0.05).PTBD also resulted in a lower risk of pancreatitis than EBD (RR=0.30,95％CI:0.15～0.59,P＜0.05),and a higher rate of successful relief of cholestatic jaundice (RR=2.77,95％CI:1.79～4.28,P＜0.05).However,the risk of bleeding for PTBD was higher (RR=2.38,95％ CI:1.12～5.05,P＜0.05),the risk of intraoperative blood transfusion increased (RR=1.59,95％ CI:1.05-2.42,P＜0.05),and the risk of celiac metastasis was also increased (PR=3.24,95％CI:1.15～9.12,P＜0.05) when compared with EBD.The incidence of celiac metastasis was as high as 4.2％.There were no significant differences between PTBD and EBD in the rates of bile leakage,intra-abdominal abscesses,hemorrhage,R0 resection,postoperative hospital stay postoperative complications and in-hospital mortality,what's more,there were no significant differences in the incidence of cholangitis,pancreatitis,and liver abscess between ENBD and EBS.Conclusions The postoperative hospital stay was similar between the two groups.ENBD was a better choice than PTBD for patients who required PBD.PTBD could be used after the failure of ENBD.
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Objective To compare the clinical outcomes of endoscopic nasobiliary drainage (ENBD) versus percutaneous transhepatic biliary drainage (PTBD) in patients with perihilar cholangiocarcinoma.Methods This retrospective case-control study was conducted on 55 patients with perihilar cholangiocarcinoma who were treated by of hepatobiliary and pancreatic surgeons at the Nanjing Drum Tower Hospital between December 2010 and August 2017.Results There was no significant difference in the effectiveness of the two drainage methods (P＞0.05).Morbidity after drainage was significantly higher in the ENBD group than the PTBD group (86.7％ vs 28.0％,P＜0.05).24 patients in the ENBD group developed postERCP pancreatic complications which included hyperamylasemia (n =20) and pancreatitis (n =4).All these patients responded well to conservative treatment.A patient in the PTBD group developed catheter tract tumor implantation.There were no significant differences in the surgical outcomes and in the different Clavien-Dindo grades of complications (P＞0.05).Abdominal infection after surgery was more common in the PTBD group than the ENBD group (64.3％ vs 26.3％,P＜0.05).Conclusion As PTBD caused catheter tract tumor implantation and increased the incidence of abdominal infection after surgery,ENBD was recommended for patients with perihilar cholangiocarcinoma treated in a tertiary medical center.
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Inspissated bile syndrome (IBS) is a relatively rare condition. Many treatment options are available, including medication, surgery, and surgical interventions, such as insertion of cholecystostomy drain, endoscopic retrograde cholangiopancreatography, internal biliary drainage, and percutaneous transhepatic biliary drainage (PTBD). We herein report the first case of IBS that was successfully treated with PTBD in a two-month-old infant in Korea. PTBD was initiated on postnatal day 72. On postnatal day 105, we confirmed complete improvement and successfully removed the catheters. This report suggests that PTBD is a viable and safe treatment option for obstructive jaundice in very young infants.
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Humans , Infant , Bile , Catheters , Cholangiopancreatography, Endoscopic Retrograde , Cholecystostomy , Drainage , Jaundice, Obstructive , KoreaABSTRACT
Objective To assess the safety and efficacy of extended liver resection using preoperative PTCD (percutaneous transhepatic cholangial drainage) and PVE (portal vein embolization) to treat patients with locally advanced hilar cholangiocarcinoma.Methods We collected and analyzed the clinical data of 27 patients with Bismuth types Ⅲ and Ⅳ hilar cholangiocarcinoma who underwent extended hepatecomy using preoperative PTCD and PVE in our hospital.Results There were 21 patients with R0 resection and 6 patients with R1 resection.The mortality rate was 0％.Eight patients died of cancer recurrence.Conclusion Preoperative PTCD and PVE combined with extended hepatectomy were safe and efficacious in treating patients with locally advanced hilar cholangiocarcinoma,which resulted in potential cure.
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Objective To investigate the clinical value of continuity nursing model in caring patients with malignant obstructive jaundice treated with percutaneous transhepatic biliary drainage (PTBD).Methods A total of 120 patients with malignant obstructive jaundice treated by PTCD were enrolled in this study.The patients were divided into the control group (n=60) and the observation group (n=60).Routine discharge guidance and health education was conducted for the patients of control group,while for the patients of observation group,in addition to conventional discharge education,the continuity nursing was executed by the responsible nurse.Continuity nursing was meant to continue the service,to guide the observation of the wound and dressing change,the observation of the quantity and quality of drainage solution,to teach the knowledge of the management of PTCD catheter as well as its complications,to guide patient's diet and rest,and to establish the continuity nursing records.Results The patients of both groups were followed up for 3 months.The patients' awareness rate of the knowledge related to PTCD tube in the observation group was significantly higher than that in the control group.The wound infection rate,the rate of PTCD tube prolapse or blockage,and the tube-related re-hospitalization rate in the observation group were strikingly lower than those in the control group (P＜0.05).Conclusion The continuity nursing model can significantly improve patients' awareness rate about the knowledge related to PTCD tube,reduce the incidences of biliary tract infection,PTCD tube prolapse or blockage,wound infection,and tube-related re-hospitalization,therefore,the quality of life can be surely improved.
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In 1980, endoscopic ultrasound (EUS) was introduced as a diagnostic tool for evaluation of the pancreas. Since the introduction of curvilinear-array echoendoscopy, EUS has been used for a variety of gastrointestinal interventions, including fine needle aspiration, tumor ablation, and pancreatobiliary access. One of the main therapeutic roles of EUS is biliary drainage as an alternative to endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD). This article summarizes three different methods of EUS-guided biliary access, with focus on technique and practical tips.
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Biopsy, Fine-Needle , Cholangiopancreatography, Endoscopic Retrograde , Cholestasis , Drainage , Endosonography , Pancreas , UltrasonographyABSTRACT
The percutaneous transhepatic biliary drainage (PTBD) is an effective intervention as a palliative therapy for relieving a jaundice and cholangitis. It may be used in place of Endoscopic retrograde cholangiopancreatography (ERCP) in the obstructive biliary disease. Recently, by developing invasive procedures, the incidence of the complications such as bleeding and perforation has been increasing in the diagnosis and treatment of hepatobiliary disease. We report here on a case of remained drawstring after PTBD in a 85-year-old man. The patient was conducted PTBD for relieving a jaundice and cholangitis. And then the patient had complained of abdominal pain constantly. A few days later, we removed PTBD and attempted ERCP for removal of CBD stone. The ERCP showed remained drawstring around ampulla of vater and we removed it by IT knife. The drawstring was successfully removed.