Background : The safety of employing a silicone catheter in hepaticojejunostomy (HJ) is generally acknowledged, as it finds widespread use in diverse medical procedures, including HJ and pancreaticojejunostomy (PJ), conducted during liver and pancreas surgeries. However, silicone catheters could cause complications, such as migration from the initial location, formation of stones or obstructions, and mucosal irritation leading to bleeding, among others. Recently, there was a case of a patient who suffered from infected pericarditis due to the migration of a silicone catheter that was initially inserted in hepaticojejunostomy. We would like to share this information to emphasize the importance of being cautious when using this type of catheter.

Methods : A 66-year-old male, post-hemihepatectomy and hepaticojejunostomy (HJ) for cholangiocarcinoma, developed pericardial effusion and dyspnea after shoulder surgery. Pericardiocentesis revealed contamination, and despite two months of care, his condition worsened. Full sternotomy uncovered a silicone catheter causing an HJ-pericardium fistula. After removal and closure, initial recovery was positive, but 1 week later, bowel contents leaked from pericardial drainage. Jejunum stump resection 4 weeks later led to a pericardial fistula, resulting in multiorgan failure and eventual demise.

Results : This report presents a unique case where a silicone catheter employed in hepaticojejunostomy led to unexpected death of patients due to its migration. The catheter moved beyond its initial anastomosis site, penetrating the jejunum and pericardium.

Conclusions : The case raises concerns about the safety of silicone catheters, emphasizing the need to exercise greater care to ensure patient safety and prevent similar complications in the future.