Endoscopic Nasobiliary Drainage Group Research Articles

A retrospective comparison of endoscopic nasobiliary drainage (ENBD) and endoscopic retrograde biliary drainage (ERBD) in the treatment of acute cholangitis

Endoscopic nasobiliary drainage (ENBD) and endoscopic retrograde biliary drainage (ERBD) can rapidly alleviate obstruction, facilitate bile drainage, and reduce pressure in the bile duct. In this study, to evaluate the effect of plastic biliary stent on the recurrence rate of choledocholithiasis in patients with actual cholangitis after endoscopic retrograde cholangioangiography (ERCP), we a comparative analysis of the efficacy and safety between ENBD and ERBD in inflammatory remission rate, complication rate, and success rate of secondary or multiple endoscopic lithotomy. A total of 347 patients undergoing ENBD and ERBD were enrolled in this retrospective study. Preoperative assessments including blood tests, electrocardiography, abdominal ultrasonography, CT scans, MRI, or MRCP were conducted on all participants. Additionally, serum CRP and amylase levels were measured using a magnetic nanobead-based immunoassay. We found that The success rate of stone removal in the ENBD group was higher than that in the ERBD group (90.8% vs. 72.7%) (P <0.0001). The remission rate of inflammation in the ERBD group (100.0%) was higher than that in the ENBD group (98.7%) (P >0.05). No significant difference was observed between the ERBD group and the ENBD group in preoperative and postoperative inflammatory indexes (total bilirubin, direct bilirubin, white blood cells, neutrophils, CRP, and serum amylase). Moreover, there were significant differences in post-ERCP pancreatitis between the ERBD group and ENBD group. These results suggest that both ENBD and ERBD can effectively improve clinical efficacy. Moreover, magnetic nanobeads have good application in serum index detection to increase detection efficiency.

Endoscopic nasobiliary drainage versus endoscopic biliary stenting for preoperative biliary drainage in patients with malignant hilar biliary obstruction: Propensity score-matched multicenter comparative study.

For preoperative biliary drainage (PBD) of malignant hilar biliary obstruction (MHBO), current guidelines recommend endoscopic nasobiliary drainage (ENBD) due to the higher risk of cholangitis after endoscopic biliary stenting (EBS) during the waiting period before surgery. However, few studies have supported this finding. Therefore, we aimed to compare the outcomes of preoperative ENBD and EBS in patients with MHBO. Patients with MHBO who underwent laparotomy for radical surgery after ENBD or EBS were included from retrospectively collected data from 13 centers (January 2014 to December 2018). We performed a 1:1 propensity score matching between the ENBD and EBS groups. These patients were compared for the following: cholangitis and all adverse events (AEs) after endoscopic biliary drainage (EBD) until surgery, time to cholangitis development after EBD, postsurgical AEs, and in-hospital death after surgery. Of the 414 patients identified, 355 were analyzed in this study (226 for ENBD and 129 for EBS). The matched cohort included 63 patients from each group. The proportion of cholangitis after EBD was similar between the two groups(20.6% vs. 25.4%, P = 0.67), and no significant difference was observed in the time to cholangitis development. The proportions of surgical site infections, bile leaks, and in-hospital mortality rates were similar between the groups. For PBD of MHBO, the proportion of AEs, including cholangitis, after EBD until surgery was similar when either ENBD or EBS was used.

Clinical Outcomes of Early Endoscopic Transpapillary Biliary Drainage for Acute Cholangitis Associated with Disseminated Intravascular Coagulation.

Acute cholangitis (AC) is often associated with disseminated intravascular coagulation (DIC), and endoscopic transpapillary biliary drainage (EBD) under endoscopic retrograde cholangiopancreatography (ERCP) is a treatment of choice. However, no evidence exists on the outcomes of EBD for AC associated with DIC. Therefore, we retrospectively evaluated the treatment outcomes of early EBD and compared endoscopic biliary stenting (EBS) and endoscopic nasobiliary drainage (ENBD). We included 62 patients who received early EBD (EBS: 30, ENBD: 32) for AC, associated with DIC. The rates of clinical success for AC and DIC resolution at 7 days after EBD were 90.3% and 88.7%, respectively. Mean hospitalization period was 31.7 days, and in-hospital mortality rate was 4.8%. ERCP-related adverse events developed in 3.2% of patients (bleeding in two patients). Comparison between EBS and ENBD groups showed that the ENBD group included patients with more severe cholangitis, and acute physiology and chronic health evaluation II score, systemic inflammatory response syndrome score, and serum bilirubin level were significantly higher in this group. However, no significant difference was observed in clinical outcomes between the two groups; both EBS and ENBD were effective. In conclusion, early EBD is effective and safe for patients with AC associated with DIC.

Utility of the inside stent as a preoperative biliary drainage method for patients with malignant perihilar biliary stricture.

Appropriate preoperative biliary drainage (PBD) is extremely important in patients with operable malignant perihilar biliary strictures. The aim of this study was to clarify the utility of inside stents in PBD. Eighty-one patients with malignant perihilar biliary stricture who underwent endoscopic nasobiliary drainage (ENBD) as the first PBD method were enrolled. Biliary stenting was performed in 61 patients during the study course (41 patients-inside stent implanted in the bile duct; 20 patients-conventional stent placed across the papilla of Vater). Twenty patients continued ENBD until surgery. Treatment outcomes were compared among the three groups. The re-intervention rate was significantly lower in the inside stent group than in the conventional stent group and ENBD group (9.8% vs 40% and 35%, P=.013 and .030, respectively), and the time to re-intervention was also significantly longer (log-rank: P=.004 and .041, respectively). Of the five patients in the inside stent group who underwent neoadjuvant chemotherapy, only one required re-intervention. There was no significant difference in the incidence of postoperative complications among the three groups. The inside stent may be a useful PBD method for patients with malignant perihilar biliary stricture.

Endoscopic Biliary Decompression by Dual Stents in Elderly Patients with Acute Cholangitis of Severe Type Due to Choledocholithiasis.

Background/Aims: Both endoscopic nasobiliary drainage (ENBD) and a plastic stent placement have some limitations in biliary decompression of elderly patients with acute cholangitis of severe type (ACST) due to choledocholithiasis. Dual stent placement may improve bile drainage without obvious discomfort. Here, we evaluated its advantages in the biliary decompression of elderly patients with ACST. Materials and Methods: A total of 257 elderly patients (≥65 years) with ACST had undergone urgent endoscopic decompression by nasobiliary catheter (ENBD group), single plastic stent (single-stent group), or dual plastic stents (dual-stent group). The data of the three groups was compared retrospectively. Results: The demographic data of the patients in the three groups were comparable. After endoscopic decompression, the serum total bilirubin and γ-glutamyl transferase levels in the dual-stent group were decreased faster than that in the single-stent group (P < .05). The abdominal pain in the dual-stent group was dramatically slighter than that in the ENBD group (P < .05). Compared with two other groups, the acute physiology and chronic health evaluation II scores were decreased dramatically quicker (P < .05) and the length of intensive care unit stay was significantly shorter (P < .05) in the dual-stent group. In the second endoscopic retrograde cholangiopancreatography, the rate of complete stone clearance in the dual-stent group was significantly higher than that in the ENBD group (P < .05). Conclusions: Dual-stent placement might be a better choice for elderly patients with ACST due to choledocholithiasis in comparison with ENBD or a single-stent placement.

Preoperative endoscopic retrograde biliary drainage increases postoperative complications after pancreaticoduodenectomy compared to endoscopic nasobiliary drainage.

Preoperative biliary drainage prior to pancreaticoduodenectomy (PD) by percutaneous transhepatic biliary drainage (PTBD) or endoscopic biliary drainage (EBD) is performed to improve liver functions, including immunity and coagulation that affect postoperative recovery in patients with jaundice. EBD can be performed through endoscopic retrograde biliary drainage (ERBD) or endoscopic nasobiliary drainage (ENBD). There is no clear consensus about which drainage is more suitable for preoperative EBD. The purpose of this study was to compare the postoperative outcomes of ENBD and ERBD performed prior to PD. Data were collected retrospectively from the medical records of 3 hospitals: Chuncheon, Kangdong and Kangnam Sacred Heart hospitals. From January 2007 to April 2019, PD was performed in 230 patients, among whom, 88 patients had undergone preoperative EBD. These 88 patients were divided into two groups according to the method of preoperative biliary drainage: ENBD versus ERBD. We compared clinical data and postoperative complications after PD between ENBD and ERBD. The overall complication rates in the ENBD group were significantly lower than in the ERBD group (26.1% vs. 57.1%, P=0.003). Postoperative pancreatic fistula (POPF) rates (11.1% vs. 38.1%, P=0.003) and postpancreatectomy hemorrhage (PPH) rates (2.2% vs. 14.3%, P=0.036) in the ENBD group were also lower than in the ERBD group. Our study provides further evidence that patients undergoing ERBD before PD are more likely to suffer POPFs and PPHs. This suggests that ENBD should be preferred in order to minimize the risk of POPFs and PPHs in patients with biliary obstruction prior to undergoing PD.

The role of stent placement above the papilla (inside-stent) as a bridging therapy for perihilar biliary malignancy: an initial experience.

Although endoscopic naso-biliary drainage (ENBD) is a popular preoperative biliary drainage (PBD) method for patients with perihilar biliary malignancy (PHBM), patient discomfort caused by the nasal tube remains a problem. This study aimed to analyze the safety and efficacy of PBD with the placement of a plastic stent above the papilla [inside-stent (IS)] as a bridging therapy. The outcomes of 78 patients with potentially resectable PHBM, of whom 29 underwent IS placement and 49 underwent ENBD were evaluated. The stent-associated complication rates were not different between the two groups (7% in the IS group and 10% in the ENBD group, P = 0.621). Catheter dislocation occurred less frequently (0% vs. 22%, P = 0.016), and the median time to recurrent biliary obstruction was longer (not reached vs. 32days, P = 0.039) in the IS group than in the ENBD group. Among the patients who underwent resection, their postoperative severe complication rates were not substantially different (26% vs. 25%, P = 0.923). IS placement is a possible alternative to ENBD as a bridge to a definitive operation for patients with resectable PHBM and a prospective trial to prove its feasibility and safety is therefore warranted.

Comparison of Curative Effect between Nasobiliary Drainage and Biliary Stenting in Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis

Background: To compare the efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in preoperative biliary drainage (PBD). Methods: ENBD and EBS related literature of patients with malignant biliary obstruction published before September 2019 were collected from PubMed, EMBASE, and Cochrane Library for comparison analysis. Revman 5.3 statistical software was used for analysis. Results: Nine studies were used for our comparative study. A total of 1435 patients were included, which consisted of 813 in the ENBD group and 622 in the EBS group. Meta-analysis showed that patients with malignant biliary obstruction who received ENBD had reductions in the rates of preoperative cholangitis (RR = 0.44, 95% CI = 0.34-0.58, P < 0.00001), preoperative pancreatitis (RR = 0.69, 95% CI = 0.50-0.95, P =0.02), stent dysfunction (RR = 0.58, 95% CI = 0.43-0.80, P =0.0008), morbidity (RR = 0.77, 95% CI = 0.64-0.93, P = 0.007) and postoperative pancreatic fistula (RR = 0.65, 95% CI = 0.45-0.92, P = 0.02) compared with patients who received EBS. Conclusions: The rates of preoperative cholangitis, preoperative pancreatitis, post-operative pancreatic fistula, stent dysfunction, and morbidity of ENBD patients were lower than those of EBS patients. In clinical practice, the physical condition of each patient and their tolerance should be fully considered. ENBD should be given priority. EBS should be replaced if stent dysfunction or intolerance occurs.

Percutaneous transhepatic biliary drainage may be the preferred preoperative drainage method in hilar cholangiocarcinoma.

Background and study aims Preoperative biliary drainage of hilar cholangiocarcinoma (HC) is controversial. The goal of this study was to compare the clinical outcome and associated complications for types II, III, and IV HC managed by percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP). Patients and methods Between January 2011 and June 2017, a total of 180 patients with II, III, and IV HC were enrolled in this retrospective cohort study. According to the drainage method, patients were divided into two groups: PTBD (n = 81) and ERCP (n = 99). This study was registered with ClinicalTrials.gov, NCT03104582, and was completed. Results Compared with the PTBD group, the ERCP group had a higher incidence of post-procedural cholangitis (37 [37.37 %] vs. 18 [22.22 %], P = 0.028) and pancreatitis (17 [17.17 %] vs. 2 [2.47 %], P = 0.001); required more salvaged biliary drainage (18 [18.18 %] vs. 5 [6.17 %], P = 0.029), and incurred a higher cost ( P < 0.05). Patients with type III and IV HC in the ERCP group had more cholangitis than those in the PTBD group (26 [36.62 %] vs. 11 [18.03 %], P = 0.018). The rate of cholangitis in patients who received endoscopic bilateral biliary stents insertion was higher than patients with unilateral stenting (23 [50.00 %] vs. 9 [26.47 %], P = 0.034), and underwent PTBD internal-external drainage had a higher incidence of cholangitis than those with only external drainage (11 [34.36 %] vs. 7 [14.29 %], P = 0.034). No significant difference in the rate of cholangitis was observed between the endoscopic unilateral stenting group and the endoscopic nasobiliary drainage group (9 [26.47 %] vs. 5 [26.32 %], P = 0.990). Conclusion Compared to ERCP, PTBD reduced the rate of cholangitis, pancreatitis, salvage biliary drainage, and decreased hospitalization costs in patients with types II, III, and IV HC. Risk of cholangitis for patients with types III and IV was significantly lower in the PTBD group.

Safety and efficacy of microwave ablation for periductal hepatocellular carcinoma with intraductal cooling of the central bile ducts through a percutaneous transhepatic cholangial drainage tube

Background and aimsBiliary thermal injury caused by microwave ablation (MWA) for a hepatocellular carcinoma (HCC) close to the central bile ducts always results in severe complications and leads to mortality. Some studies have demonstrated that intraductal cooling of the biliary tract with chilled saline during thermal ablation can successfully prevent these complications. In this study, we present a novel bile duct cooling technique through a percutaneous transhepatic cholangial drainage (PTCD) tube for preventing biliary thermal injury caused by MWA, and compare the feasibility and safety of the intraductal cooling technique when performed with a PTCD tube and with an endoscopic nasobiliary drainage (ENBD) tube. MethodsParticipants were randomly assigned to undergo MWA of HCC with intraductal chilled saline perfusion through a PTCD tube or an ENBD tube. The main study outcomes were bile duct complications related to MWA and local tumor recurrence. p value < 0.05 was considered to indicate a statistically significant difference. ResultsA total of 23 patients with an HCC (23 nodules) close to a central bile duct were enrolled in this study. Of these patients, 12 had a PTCD tube and 11 had an ENBD tube placed into the hepatic duct close to the lesions. There were no PTCD- and ENBD-related mortality cases. There was no complication related to the PTCD procedure; however, 3 patients (27.27%) developed acute pancreatitis and 1 patient (9.09%) had hemorrhage in the ENBD group (p = 0.037). One patient (8.33%) in the PTCD group had bile leakage and 2 patients (18.18%) in the ENBD group developed a biloma. Within 5 years, 1 patient in the PTCD group and 2 patients in the ENBD group had local recurrence. There was no significant difference in local recurrence, nonlocal hepatic recurrence, mortality rate, or median cumulative overall survival between the 2 groups. ConclusionsThe intraductal cooling technique using a PTCD tube is a feasible and effective method for preventing bile duct thermal injury caused by MWA for an HCC close to the central bile ducts. It does not increase local recurrence and may be safer than intraductal cooling through an ENBD tube.

Comparison between endoscopic retrograde biliary drainage and endoscopic nasobiliary drainage in treatment of acute cholangitis

Objective To compare the safety and effectiveness of endoscopic retrograde biliary drainage (ERBD) and endoscopic nasobiliary drainage (ENBD) in treatment of acute cholangitis. Methods A retrospective analysis was performed on data of 272 patients with acute cholangitis who underwent emergent endoscopic retrograde cholangiopancreatography (ERCP) in Beijing Chaoyang Hospital from January 2009 to June 2017. Patients were divided into ERBD group (n=143) and ENBD group (n=129) according to the drainage measures. In the ERBD group, there were 63 cases of grade Ⅰ (mild) acute cholangitis, 51 of grade Ⅱ (moderate), and 29 of grade Ⅲ (severe), and the corresponding cases in the ENBD group were 54, 37 and 38, respectively. The rate of improvement of inflammation, ERCP-related complications and interventions to drainage were compared between the two groups in all patients and each grade. Results The rates of improvement of inflammation in the ERBD group and the ENBD group were 89.5% (128/143) and 94.6% (122/129), respectively, in overall patients (χ2=2.399, P=0.126), 93.7% (59/63) and 98.1% (53/54), respectively, in grade Ⅰ patients (χ2=0.548, P=0.459), 90.2% (46/51) and 94.6% (35/37), respectively, in grade Ⅱ patients (χ2=0.125, P=0.724), and 79.3% (23/29) and 89.5% (34/38), respectively, in grade Ⅲ patients (χ2=0.657, P=0.418). The incidence of ERCP-related complications in the ERBD group and the ENBD group were 11.9% (17/143) and 7.8% (10/129), respectively, in overall patients (χ2=1.298, P=0.225), 9.5% (6/63) and 7.4% (4/54), respectively, in grade Ⅰ patients (χ2=0.006, P=0.939), 13.7% (7/51) and 8.1% (3/37), respectively, in grade Ⅱ patients (χ2=0.230, P=0.632), and 13.8% (4/29) and 7.9% (3/38), respectively, in grade Ⅲ patients (χ2=0.144, P=0.705). There were no significant differences in the rate of improvement of inflammation and ERCP-related complications between the two groups. The incidences of interventions to drainage in the ERBD group and the ENBD group were 10.5% (15/143) and 3.1% (4/129), respectively, in overall patients (χ2=5.699, P=0.017), 6.3% (4/63) and 1.9% (1/54), respectively, in grade Ⅰ patients (χ2=0.548, P=0.495), 9.8% (5/51) and 5.4% (2/37), respectively, in grade Ⅱ patients (χ2=0.125, P=0.724), and 20.7% (6/29) and 2.6% (1/38), respectively, in grade Ⅲ patients (χ2=3.965, P=0.046). There were significant differences in the incidence of interventions to drainage between the two groups in overall and grade Ⅲ patents. Conclusion ERBD and ENBD are equally safe and effective in treatment of different grades of acute cholangitis, but ENBD can reduce the incidence of interventions to drainage. Key words: Cholangiopancreatography, endoscopic retrograde; Stent; Nasobiliary drainage; Acute cholangitis

Clinical outcomes of preoperative endoscopic nasobiliary drainage versus percutaneous transhepatic biliary drainage for patients with perihilar cholangiocarcinoma

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). 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. Key words: Perihilar cholangiocarcinoma; Biliary drainage; Endoscopic nasobiliary drainage; Percutaneous transhepatic biliary drainage

Clinical efficacies of free endoscopic nasobiliary drainage in primary duct closure following laparoscopic common bile duct exploration: a multicenter retrospective study (A report of 312 cases)

Objective To investigate the clinical efficacies of free endoscopic nasobiliary drainage (ENBD) in primary duct closure (PDC) following laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Methods The retrospective cohort study was conducted. The clinical data of 312 patients with extrahepatic bile duct stones accompanied with or without cholecystolithiasis who were admitted to the 11 medical centers [86 in the Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 62 in the Second Affiliated Hospital of Zhejiang University School of Medicine, 44 in the West China Hospital of Sichuan University, 29 in the First Affiliated Hospital of Xi′an Jiaotong University, 27 in the First Hospital Affiliated to Army Medical University (Third Military Medical University), 25 in the Hunan Provincial People′s Hospital, 17 in the Beijing Friendship Hospital of Capital Medical University, 10 in the First Affiliated Hospital of Hainan Medical University, 5 in the Henan Provincial People′s Hospital, 4 in the Beijing Tian Tan Hospital of Capital Medical University, 3 in the First Affiliated Hospital of Fujian Medical University] from January 2011 to June 2017 were collected. All patients underwent LCBDE+ PDC, and 81 and 231 patients with and without ENBD were respectively allocated into the ENBD group and PDC group. Observation indicators: (1) comparisons of operation situations; (2) comparisons of postoperative recovery; (3) comparisons of postoperative complications; (4) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative complications up to June 2017. Measurement data with normal distribution were represented as ±s. Comparison between groups was analyzed by the t test. Measurement data with skewed distribution were represented M [interquartile range (IQR)], and comparison between groups was analyzed by the nonparametic test. Comparisons of count data were analyzed using the chi-square test and Fisher exact probability. Results (1) Comparisons of operation situations: all the 312 patients underwent successful laparoscopic LCBDE + PDC, without conversion to open surgery, including postoperative death of 1 patient in the PDC group. The common bile duct diameter, cases using interrupted sutures, continuous sutures, absorbable threads and non-absorbable threads were respectively (1.2±0.4)cm, 106, 125, 195, 36 in the PDC group and (1.1±0.5)cm, 76, 5, 79, 2 in the ENBD group, with statistically significant differences between groups (t=2.497, χ2=56.706, 8.457, P 3 mm), normal and abnormal Oddi sphincter contraction function, volume of intraoperative blood loss and operation time were respectively 2.1±1.7, (1.1±0.6)cm, 148, 83, 226, 5, 20 mL (10-45 mL), (116±49)minutes in the PDC group and 1.9±1.6, (1.0±0.6)cm, 49, 32, 75, 6, 20 mL (15-30 mL), (113±23)minutes in the ENBD group, with no statistically significant difference between groups (t=1.021, 0.329, χ2=0.329, 3.428, Z=1.147, t=0.521, P>0.05). The further analysis: of 312 patients, cases and time using interrupted sutures and continuous sutures were respectively 182, 130 and (133±49)minutes, (103±34)minutes, with a statistically significant difference between groups (t=-6.605, P 0.05). Of 312 patients, cases, operation time, volume of intraoperative blood loss and postoperative complications using absorbable threads and non-absorbable threads were respectively 274, (116±44)minutes, 20 mL (15-40 mL), 33 and 38, (115±35)minutes, 18 mL (10-26 mL), 6, with no statistically significant difference between groups (Z=0.971, t=0.023, χ2=0.154, P>0.05). (2) Comparisons of postoperative recovery: recovery time of gastrointestinal function, time of abdominal drainage-tube removal, using time of antibiotics and duration of hospital stay were respectively (2.0±1.5)days, (4.0±2.4)days, (4.0±2.8)days, (5.5±3.0)days in the PDC group and (4.0±1.9)days, (6.9±3.5)days, (10.0±3.9)days, (11.1±3.7)days in the ENBD group, with statistically significant differences between groups (t=-9.507, -8.258, -15.103, -13.575, P 0.05). (4) Follow-up situations: of 312 patients, 252 were followed up for 2-67 month, with a median time of 15 months, including 175 in the PDC group and 77 in the ENBD group. During the follow-up, there was no occurrence of jaundice, cholangitis and pancreatitis, and stone recurrence and postoperative cholangiostenosis were not detected by abdominal color Doppler ultrasound or CT or magnetic resonanced cholangio-pancreatography. Conclusion On the basis of grasping operative indication strictly, ENBD in PDC following LCBDE for choledocholithiasis is safe and effective. Key words: Choledocholithiasis; Common bile duct exploration; Primary duct closure; Laparoscopy; Endoscopic nasobiliary drainage; Multicenter; Retrospective study

The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma.

Background/Aims:Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma.Patients and Methods:A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated.Results:The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared.Conclusions:The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.

Nasobiliary drainage can reduce the incidence of post-ERCP pancreatitis after papillary large balloon dilation plus endoscopic biliary sphincterotomy: a randomized controlled trial

Background and aims: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis can be reduced following endoscopic papillary balloon dilation with the placement of an endoscopic nasobiliary drainage (ENBD) catheter. The aim of this study was to determine whether the placement of an ENBD reduces the risk of post-ERCP pancreatitis following endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.Methods: A total of 160 patients with bile duct stones were randomly assigned (1:1) to an ENBD group or no-ENBD group. The primary outcome of this study was the incidence of post-ERCP pancreatitis. The secondary outcome was the incidence of post-ERCP hyperamylasemia.Results: In total, 160 patients were randomized, and 155 were found to be eligible for the analysis. The two groups were similar regarding clinical and demographic factors as well as patient- and procedure-related risk factors for post-ERCP pancreatitis. Post-ERCP pancreatitis developed in 9 patients, that is, 8/77 (10.4%) of the control group and 1/78 (1.28%) of the ENBD group (p = .018; per protocol analysis). Intention to treat analysis also revealed that ENBD reduced the rate of post-ERCP pancreatitis (8/80 (10%) in the control group vs. 1/80 (1.25%) the ENBD group (p = .034)). Multivariate regression analysis identified not undergoing ENBD as an independent risk factor for post-ERCP pancreatitis (ENBD compared with no-ENBD: OR 0.087, 95% CI 0.011–0.734; p = .025).Conclusion: This study demonstrated that placement of an ENBD was effective and safe for the prevention of post-ERCP pancreatitis in patients undergoing endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.

Best option for preoperative biliary drainage in Klatskin tumor: A systematic review and meta-analysis.

The operative treatment combined with preoperative biliary drainage (PBD) has been established as a safe Klatskin tumor (KT) treatment strategy. However, there has always been a dispute for the preferred technique for PBD technique. This meta-analysis was conducted to compare the biliary drainage-related cholangitis, pancreatitis, hemorrhage, and the success rates of palliative relief of cholestasis between percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD), to identify the best technique in the management of KT.PubMed, EMBASE, and Web of Science were searched systematically for prospective or retrospective studies reporting the biliary drainage-related cholangitis, pancreatitis, hemorrhage, and the success rates of palliative relief of cholestasis in patients with KT. A meta-analysis was performed, using the fixed or random-effect model, with Review Manager 5.3.PTBD was associated with lower risk of cholangitis (risk ratio [RR] = 0.49, 95% confidence interval [CI]: 0.36-0.67; P < .00001), particularly in patients with Bismuth-Corlette type II, III, IV KT (RR = 0.50, 95% CI: 0.33-0.77; P = .05). Compared with EBD, PTBD was also associated with a lower risk of pancreatitis (RR = 0.35, 95% CI: 0.17-0.69; P = 0.003) and with higher successful rates of palliative relief of cholestasis (RR = 1.20, 95% CI: 1.10-1.31; P < .0001). The incidence of hemorrhage was similar in these 2 groups (RR 1.29, 95% CI: 0.51-3.27; P = .59). The risk of biliary drainage-related cholangitis (RR = 1.96, 95% CI: 0.96-4.01; P = .06) and pancreatitis (RR = 1.62, 95% CI: 0.76-3.47; P = .21) was similar between endoscopic nasobiliary drainage groups and biliary stenting.In patients with type II or type III or IV KT who need to have PBD, PTBD should be performed as an initial method of biliary drainage in terms of reducing the incidence of procedure related cholangitis, pancreatitis, and improving the rates of palliative relief of cholestasis. Well-conducted randomized controlled trials with a universial criterion for PBD are required to confirm these findings.

ENBD is Associated with Decreased Tumor Dissemination Compared to PTBD in Perihilar Cholangiocarcinoma

BackgroundLittle is known regarding the risk of tumor dissemination when percutaneous biliary drainage is used before surgical resection of perihilar cholangiocarcinoma (PHC). We aimed to compare the incidence of tumor dissemination after preoperative endoscopic nasobiliary drainage (ENBD) with that after percutaneous transhepatic biliary drainage (PTBD) for PHC. MethodsData from 208 consecutive patients who underwent PHC resection between 2000 and 2013 were retrospectively analyzed. The influence of drainage type on incidence of tumor dissemination was examined. Seventy-six patients underwent ENBD (37%), 87 underwent PTBD (42%), and 45 underwent surgery without preoperative biliary drainage (WD, 22%). ResultsThe respective 2- and 5-year estimated cumulative incidences of tumor dissemination in the ENBD group (11.8/14.6%) were lower than in the PTBD group (28.8/35.9%, p = 0.003) and equivalent to that in the WD group (11.2/15.9%, p = NS). PTBD (hazard ratio [HR] vs. ENBD, 2.80) was an independent risk factor for postoperative tumor dissemination in the multivariate analysis. The 2- and 5-year disease-specific survival rates were higher in the ENBD group (67.6/47.3%) than in the PTBD group (56.6/27.8%, p = 0.032) and equivalent to that in the WD group (64.9/53.8%, p = NS). However, drainage type was not an independent risk factor in multivariate analysis of disease-specific survival. ConclusionFor patients with PHC, the associated risk of postoperative tumor dissemination in the ENBD group was lower than in the PTBD group and equivalent to that in the WD group. Thus, ENBD is the ideal procedure for preoperative biliary drainage.

Endoscopic Nasobiliary Drainage Help to Prevent the Postoperative Complications of ERCP for Choledocholith Removal

Aims: In order to investigate the preventive effect of endoscopic nasobiliary drainage (ENBD) on the postoperative complications of ERCP with endoscopic sphincterotomy (EST) for choledocholith. Methods: we collected 180 patients with choledocholith who received the treatment of ERCP for extracting stones between January 2007 and June 2009. All of the 180 patients were divided into two groups: the ENBD group which, including 80 patients, were placed with ENBD, and the control group, including the residual 100 patients, were not placed with ENBD. We measured the scrum amylase levels within 24 hours, before and after ERCP. Meanwhile, the incidences of hyperamylasemia, acute pancreatitis, cholangitis and sphincter of Oddi dysfunction (SOD) were observed after ERCP. Results: The ENBD group shown lower scrum amylase levels after ERCP (225.78±178.62 vs. 563.08±201.24, P 0.05) before ERCP. At the same time, ENBD group were found with less incidences of hyperamylasemia (5% vs. 18%, P 0.05) than control group. Conclusion: Out results suggested that ENBD can prevent the complications of hyperamylasemia, acute pancreatitis and SOD after ERCP effectively.

The effects of different preoperative biliary drainage methods on complications following pancreaticoduodenectomy.

The objective of this study was to investigate the effects of different preoperative biliary drainage (PBD) methods on complications in jaundiced patients following pancreaticoduodenectomy. We retrospectively analyzed 270 extrahepatic bile duct cancer patients who underwent pancreaticoduodenectomy. A total of 170 patients without PBD treatment were defined as the non-PBD group. According to different PBD methods, 45, 18, and 37 patients were classified into the percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD), and endoscopic retrograde biliary stent (ERBS) groups, respectively. Clinical characteristics and complications were compared among the 4 groups.Preoperative cholangitis occurred in 14 (8.2%) and 8 (21.6%) patients in the non-PBD and ERBS group, respectively (P = 0.04). Compared with the non-PBD group, delayed gastric emptying (DGE) and wound infection occurred significantly more often in the ERBS group. The incidence of severe complications was significantly lower in the PTBD group than the non-PBD group (P = 0.03). Postoperative hospital stay and complication rates were significantly higher in the ERBS group than the PTBD group. There were no significant differences in complications between ENBD and other groups.In conclusion, PTBD can improve surgical outcomes by reducing severe complication rate in jaundiced patients following pancreaticoduodenectomy. ERBS increased the rates of DGE and wound infection due to high incidence of cholangitis before operative intervention and should be avoided. ENBD carried no special effect on complications and needs further analysis.

Prevention of pancreatitis after papillary balloon dilatation by nasobiliary drainage: a randomized controlled trial.

Endoscopic papillary balloon dilation (EPBD) was associated with a higher rate of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The purpose of this study was to determine whether placement of an endoscopic nasobiliary drainage (ENBD) catheter can also prevent PEP after EPBD. A total of 93 patients, who with proven common bile duct (CBD) stones, received EPBD were enrolled this trial. They were randomly divided into ENBD group (n = 45) and no-ENBD group (n = 48) according whether undergone an ENBD procedure after EPBD. Their demographics, laboratory, procedural data were collected, and pancreaticobiliary complications were followed. The number of patients with serum amylase levels above the normal upper limit (>180 U/L) did not differ between groups. However, compared with ENBD group, more patients in No-ENBD group had levels greater than three times the normal limit (>540 U/L) (11/48 vs 3/45, P = 0.0285), and more patients developed to PEP (7/48 vs 0/45, P = 0.0250). During follow-up, the numbers of patients undergone cholecystectomy, cholangitis and recurrence of CBD stones were similar. There was also no significant difference in the cumulative rate of recurrent pancreaticobiliary complications between the two groups (P = 0.452). EPBD followed by insertion of an ENBD catheter can prevent PEP, and routine ENBD catheter placement is recommended after an EPBD procedure.