Patient Name:     ,           

DOB:        SEX:    

Ordering Physician:     ,    

 

PROCEDURE: 

  1. Sheath cholangiogram
  2. Biliary catheter replacement          

INDICATION:    

DATE:    

OPERATORS:   John Doe, MD (Attending)/Jane Doe, MD (Fellow)     

MEDICATIONS: Versed     mg IV, fentanyl     mcg IV, Zosyn 3.375 gm IV 

CONTRAST:     ml non-ionic contrast

FLUOROSCOPY TIME:      minutes

CATHETER:     French     biliary drain

COMPLICATIONS: None

 

TECHNIQUE: The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risk of sepsis was detailed and accepted. Written informed consent was obtained.

The existing catheter and surrounding soft tissues were prepped and draped in sterile fashion. Local anesthetic was injected at the catheter entry site.

Contrast was injected through the existing tube to confirm position.  

A 0.035″ glidewire was negotiated through the catheter into the small bowel.  The catheter was removed and a 5F Kumpe catheter was used to exchange the glidewire for a 0.035″ Amplatz guidewire.  The Kumpe was exchanged for a ____ French sheath.  A pull back sheath cholangiogram was performed.

The sheath was removed and a new ____French Bentec internal/external biliary drain was placed coaxially over a____ French Van Andel catheter.  Contrast was injected to confirm tube position.  The tube was ______.  The catheter was secured to the skin with 2-0 Ethilon.  The patient tolerated the procedure well without immediate complications.

 

FINDINGS: Comparison is made to a prior study dated    .

  1. Cholangiogram through the catheter demonstrates    ______
  2. The new catheter is appropriately positioned with the distal tip in the _____ and the proximal side hole in a peripheral bile duct.

 

IMPRESSION: 

  2. Uneventful image guided replacement of a biliary catheter as described.

PLAN: