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.