Nasobiliary Tube Research Articles

Effect of reverse-α fixation of nasobiliary tube after endoscopic nasobiliary drainage

Objective To investigate a new method for fixation of nasobiliary tube after endoscopic nasobiliary draniage (ENBD). Methods A total of 1 127 patients underwent ENBD were randomly divided into control (traditional method) and experimental group (reverse-α method). The differences in the incidence of complications, patient self-comfort and the length of taking care of nasobiliary tube were evaluated between two groups during the period of indwelling nasobiliary tube. Results The incidence of nasal mucosa of pressure sore and dystopy of nasobiliary tube in the experimental group were 14 cases and 7 cases comparing with 31 cases and 28 cases in the control group (χ2=7.569, 14.071, respectively; P<0.01). Compared with the control group, the scores of nasal comfort and average length of taking care were (3.96±0.84) and (72.2±9.7)s higher than those of the control group (t=8.221, 10.063, respectively; P<0.05). Conclusions Patient comfort during indwelling nasobiliary tube after ENBD can be effectively improved by using 'reverse-α method’ to fix the tube. It can also reduce the complications and improve the care efficiency. Key words: Nursing care; Nasobiliary tube drainage; Fixation

Travel Jaundice Caused by Pathological Common Bile Duct Angulation: A Case Report

Background: Physiologically, the common bile duct (CBD) turns to the right as it descends towards the duodenum. The degree of angulation in this turn is dependent on the position of the patient, liver mobility and points that stabilize the CBD, such as postoperative adhesions. In extreme cases, the sharpness of this angulation can by induce jaundice and recurrent choledocholithiasis. In this report, the authors describe a woman for whom pathological angulation occurs only in a sitting position. In view of periodic appearance of symptoms to establish the correct diagnosis it is difficult, therefore we proposed a method of enabling confirmation of the existence of this unusual pathology. In the available publications we not found a similar description of the disease and methods for its diagnosis. Case presentation: The paper presents the a 55-year-old woman with recurrent pain in the right upper quadrant with comorbid jaundice most often after a long journey by car. In the past patient underwent classical cholecystectomy with revision of the CBD and endoscopic sphincterotomy. Despite this treatment, symptoms continued to recur. On that basis, we decided examine her biliary tree in a sitting position using for this purpose nasobiliary tube (NBT). The image acquired in this way revealed the presence of a pathological CBD angulation, which explained the symptoms. Conclusion: Bending to the bile duct is rare and difficult to diagnose cause transient jaundice. However, in some cases where the clinical picture points to the cause, cholangiography using the NBT can be the basis to determine the correct diagnosis.

Open surgery for hepatic hydatid disease.

Hydatid disease is a zoonosis caused by the larvae of Echinococcus granulosus . Humans are an intermediate host and are usually infected by direct contact with dogs or indirectly by contaminated foods. Hydatid disease mainly involves the liver and lungs. The disease can be asymptomatic. Imaging techniques such as ultrasonography and computed tomography are used for diagnosis. The growth of hydatid cysts can lead to complications. Communication between bile duct and cysts is a common complication. The goal of treatment for hydatid disease is to eliminate the parasite with minimum morbidity and mortality. There are 3 treatment options: surgery, chemotherapy, and interventional procedures. Medical treatment has low cure and high recurrence rates. Percutaneous treatment can be performed in select cases. There are many surgical approaches for managing hydatid cysts, although there is no best surgical technique, and conservative and radical procedures are used. Conservative procedures are usually preferred in endemic areas and are easy to perform but are associated with high morbidity and recurrence rates. In these procedures, the parasite is sterilized using a scolicidal agent, and the cyst is evacuated. Radical procedures include hepatic resections and pericystectomy, which have high intraoperative risk and low recurrence rates. Radical procedures should be performed in hepatobiliary centers. The most common postoperative complications are biliary fistulas and cavity-related complications. Endoscopic retrograde cholangiopancreatography can be used to diagnose and treat biliary system complications. Endoscopic sphincterotomy, biliary stenting, and nasobiliary tube drainage are effective for treating postoperative biliary fistulas.

Endoscopic treatment of delayed colon perforation: the enteroscopy overtube approach.

Delayed perforation is a rare complication of therapeutic colonoscopy, and it is severe and sometimes lethal. This paper reports on a new minimally invasive method for the treatment of delayed colonic perforation. Three patients with delayed colonic perforation underwent the therapy, which involved three steps: (1) closure with endoclips and loop, (2) overtube placement, and (3) antibiotic wash through a nasobiliary tube. The procedure was successful in all three patients and no recurrence was observed during 5 - 41 months of follow-up. Although this study involved only a small number of patients and no control arm, the method involving an overtube appears to be a feasible and effective endoscopic treatment for delayed colonic perforation.

Concurrent autoimmune pancreatitis and primary Biliary cirrhosis: a rare case report and literature review

BackgroundBoth autoimmune pancreatitis (AIP) and primary biliary cirrhosis (PBC) are related to various diseases. But the concurrence of AIP and PBC is extremely rare, with only 2 cases reported. Here we report the concurrence of AIP and PBC in a Chinese patient for the first time.Case presentationA 65-year-old male was admitted to our hospital with jaundice, pruritus, mild abdominal pain and darkening urine. Serum alkaline phosphatase, γ-glutamyltransferase, bilirubin and IgG4 were prominently elevated. The antimitochondrial antibody was positive. Radiological examination revealed diffusive enlargement of the pancreas. Pancreatic biopsy showed lymphoplasmacytic infiltration, fibrosis and abundant IgG4+ plasma cells. The patient was diagnosed with AIP and PBC. Nasobiliary tube was placed to facilitate biliary drainage. A combination therapy of steroid and UDCA was administered and the patient was gradually recovered, during which the patient was complicated with biliary infecion, herpes zoster and pulmonary abscess.ConclusionWe present this case together with literature evidence to support the concurrence of AIP and PBC, share our experience of using combination therapy with steroid and UDCA, and raise the awareness of infectious complications in immunosuppressed patients.

Use of nasobiliary tube for prevention of stone recurrence after endoscopic retrograde cholangiopancreatography for common bile duct stones

Use of nasobiliary tube for prevention of stone recurrence after endoscopic retrograde cholangiopancreatography for common bile duct stones

Placement of a Nasobiliary Tube for Treatment of Cholangiosepsis

Nasobiliary drainage catheters allow effective decompression and flushing in cases with cholangitis and obstructive jaundice. Here the author describes the technique in a patient with obstructing cholangiocarcinoma and severe cholangiosepsis. The key learning point from this procedure is that a combination of a plastic endoprosthesis with a nasobiliary tube allows continuous lavage of the bile ducts as an optimal treatment for suppurative cholangitis. This article is part of an expert video encyclopedia.

Application of nasobiliary tube placement during laparoscopic choledochotomy in primary suture of common bile duct

Objective To evaluate the clinical value of nasobiliary tube placement during laparoscopic choledochotomy in primary suture of common bile duct. Methods A case-control study was performed on 42 patients undergoing this procedure. The patients who were chosen according to the inclusive criteria were confirmed as free of residual stones, stricture or obstruction of common bile duct. Abdominal drainage tubes were routinely placed. Results The nasobiliary tube was successfully placed on all of the pateints. No bile leakage was found. Conclusions Nasobiliary tube placement during laparoscopic choledochotomy is of great value in the prevention of bile leakage or bile duct stricture secondary to choledochotomy. This procedure is simple, safe, reliable, and effective. It is worth popularizing in most of the hospitals. Key words: Laparoscopy; Chotedochotomy; Nasobillary tube; Primary suture

Positioning of nasobiliary tube using magnet-loaded catheters

In endoscopic nasobiliary drainage (ENBD), repositioning the catheter from the mouth to the nose is complicated. We devised a method using catheters with magnets and verified its utility and safety. We prospectively enrolled 20 patients undergoing ENBD at Yokohama City University Hospital. The procedures were successful in all 20 cases and no case required a change of operators to a senior doctor. The mean time for the procedure was 36.6 seconds. The emetic reflex was induced 0.5 times on average using the magnet method. The mean X-ray exposure time was 29.6 seconds. No complications occurred. The magnet-loaded catheter method for positioning the ENBD catheter before finally leading it through the nose took little time and was performed successfully and safely. Therefore, the magnet method could become the first choice among techniques for ENBD catheter placement.

New stent exchange technique following endoscopic ultrasound‐guided nasobiliary drainage (with video)

Video S1 Nasobiliary tube was cut using scissors (FS-3L-1; Olympus Medical Systems, Tokyo, Japan) and loop cutter forceps (FS-5L-1; Olympus). The remnant tube was cannulated using a wire-guided technique via the endoscopic retrograde cholangiopancreatography catheter. The tube was trapped in the snare with the snare-over-the-wire technique. After removing the remnant tube via the working channel with the snare-over-the-wire technique, a 7-Fr plastic stent was put in place without complications. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Comparison of endoscopic retrograde cholangiopancreatography between elderly and younger patients for common bile duct stones.

Choledocholithiasis is increasing in elderly subjects. The introduction of endoscopic retrograde cholangiopancreatography with biliary sphincterotomy has almost replaced surgery in the treatment of this condition. The aim of the present study was to evaluate the rates of successful clearance of common bile duct stones and the endoscopic techniques used in a population aged 75 years or older compared with those in a younger age group. A retrospective analysis was made of data related patients who underwent endoscopic retrograde cholangiopancreatography for choledocolithiasis in the period 2010-2011. For all patients, factors such as sex, age at diagnosis, endoscopic treatment (stone extraction using baskets and balloon, mechanical lithotripsy and balloon dilatation of the ampulla, placement of a stent or a naso-biliary tube) and need of surgery were analysed. Two groups of patients were identified: patients aged <75 years (Group A) and patients aged ≥75 years (Group B). For the statistical analysis Mann-Whitney test and Fischer's Exact test were used. A total of 234 patients were enrolled in the study (94 in Group A, 140 in Group B). No statistically significant differences were observed as far concerns sex, previous cholecystectomy, gallbladder stones and periampullary diverticula, but only for common bile duct dilatation. Complete clearance of common bile duct stones was achieved in 230 patients (97.5%). The present data are in keeping with those presented in the literature, which confirm that endoscopic retrograde cholangiopancreatography is a safe and effective procedure also in older patients.

Endoscopic nasobiliary tube drain (ENBTD) prior to laparoscopic cholecystectomy in acute± complicated cholecystitis: Influence on the rate of complications

Background and aim: It is not known to what extent surgical outcome of laparoscopic cholecystectomy for acute or complicated cholecystitis differ from those for the chronic form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. Also, risk factors may predispose to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) including the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct ofLuschka. A method to prevent the bile duct injury is a preoperative placement of an endoscopic nasobiliary tube drain (ENBTD). The aim of this review was to evaluate the efficacy ofENBTD assisted LC regarding prevention of intraoperative and postoperative bile duct injury or leakage. Methods: From April 2009 to June 2011, a total of 96 consecutive ENBTD assisted LCs for acute cholecystitis± complicated cholecystitis performed in our institutions were reviewed during this period. Results: Anomalous cystic duct confluence was detected in 3 cases and an accessory hepatic duct was detected in 2 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery or conversion rate to laparotomy, but significant decrease in the frequency of bile duct injury and leakage compared to the standard LC. Conclusion: Bile duct anomalies were seen in 6.72% ofLC cases. Placement of an ENBTD tube prior to LC in acute cholecystitis± empyema or gangerenous cholecystitis had successfully decreased the incidence of complications.

Therapeutic transjejunal endoscopy for the treatment of biliary complications after choledochojejunostomy

The present study aimed to assess the value of endoscopic jejunostomy for post-biliary intestinal anastomosis biliary complications. The clinical data of the endoscopic therapies by jejunal approach for post-biliary intestinal anastomosis biliary complications in 13 patients (16 surgeries in total) were retrospectively analyzed. The surgical success rate was 100% (16/16). Nasobiliary tube detention was performed for 2 patients, plastic stent placement for 5 and biliary metal stent placement for 4. The remaining two patients did not retain any drainage tube or bracket after surgery. The incidence rate of intraoperative anastomotic stenostomia was 76.9% (10/13). A noticeable postoperative decrease in bilirubin levels was observed in 10 patients. The level of gallstone-free patients was 75% (3/4). There were 10 cases in which cholangitis remission or no attack was identified. Post-operative incisional infection occurred in 3 patients, hepatophyma in 1 and an intestinal fistula in 1. Endoscopic therapy by jejunal approach for post-biliary intestinal anastomosis biliary complications has the virtue of being safe, effective and minimally invasive. It has extensive potential applications in clinical practice.

EST 後再発し, ESWL により治療しえた巨大総胆管結石症の1例

EST 後再発し, ESWL により治療しえた巨大総胆管結石症の1例

Transoralgastric Gastroscopic Debridement for Peripancreatic Abscess: A Special Case Report

Transoralgastric debridement for pancreatic abscess is one of the successful applications of NOTES in clinical practice. We present a case report as follows: a 71-year-old female was hospitalized due to acute biliary pancreatitis. Three weeks after onset, the secondary abdominal CT showed a peripancreatic abscess. A passageway between the gastric wall and the abscess was made with a high-frequency puncher under the guidance of an ultrasonic gastroscope and then a gastroscope was directly inserted into the abscess, and a large amount of solid necrotic tissue was taken out with foreign body forceps and snare under the direct vision of a gastroscope. Then a 8.5F double-J stent and a nasobiliary drainage tube were inserted. After three times of intra-abdominal abscess debridement and repeated rinsing with an antibiotic solution, abdominal CT revealed the intra-abdominal abscess nearly disappeared and the patient discharged from hospital.

Transnasal pharyngoscopy to assist nasobiliary tube placement: a simple technique to avoid injury to the patient, endoscopist, and endoscope

We read with interest the article by Dr Baron [1] on his “safe” transnasoral endoscopic technique to facilitate nasobiliary catheter placement while avoiding injury to the endoscopist. Oral-nasal transfer of a nasal transfer tube (NTT) is the final step of endoscopic nasobiliary drainage (ENBD), which involves introduction of a NTT from the nose to the posterior oropharynx. This blind insertion process, similar to nasogastric tube placement, can cause pain and nasomucosal injury. Moreover, according to most manufacturers’ instructions, a pair of forceps is used to grasp the NTT out of the posterior oropharynx; however, this rigid instrument may also cause mucosal injury to the oral cavity and oropharynx ([Fig. 1 a]). Sometimes endoscopists risk their fingers being bitten during this procedure ([Fig. 1 b]).

Reply to Hu

I appreciate the comments raised by Dr Hu regarding the method I described for transferring a nasobiliary tube from the mouth to the nose, and especially the concerns raised about nasal trauma and endoscope damage. Our patient was actually edentulous, though a bite block was in place nonetheless. The self-limited nasal bleeding our patient experienced may also have been due to the prior unsuccessful attempt at passage of the transfer tube. Using the technique I described the assistant at the head of the bed needs to ensure that the bite block is not expelled if moderate sedation or monitored anesthesia care is administered.

Complete endoscopic removal of a necrotic spleen (with video)

A 78-year-old woman underwent subtotal gastrectomy, Billroth II reconstruction, and splenic preserving distal pancreatectomy for locally invasive gastric adenocarcinoma (Fig. 1A). Abdominal CT performed 20 days later to evaluate abdominal pain demonstrated a gastrojejunostomy anastomotic leak with adjacent abscess. Splenic necrosis was evident because of a lack of enhancement with emphysematous changes at the hilum contiguous with the abscess (Fig. 1B). Percutaneous catheter placement was impossible without traversing the pleural space, and her hostile abdomen prohibited an anterior surgical approach. Thus, endoscopic therapy was undertaken after informed consent. A therapeutic channel upper endoscope (GIF-1T-Q180; Olympus Medical Systems, Center Valley, Pa) was introduced into the stomach where a large defect was found proximal to the anastomosis. After suctioning purulent material, the endoscope was advanced into the cavity where a large amount of necrotic tissue was debrided with a 2-cm spiral snare (SD-230U-20; Olympus Medical Systems) (Fig. 2A; Video, available online at www.giejournal. org) and was found to be devitalized spleen (Figs. 2B). After additional debridement, a 10F pigtail nasobiliary tube was left in the cavity for irrigation. Later, a CT-guided percutaneous drain was placed in the cavity for irrigation because the debridements had opened a window into the cavity. Four endoscopic debridements resulted in total splenic necrosectomy (Fig. 3A). The percutaneous drain crossed the pleural space, resulting in an abdominopleural fistula and empyema. Therefore, two 10F, 5-cm, double-pigtail stents were placed transgastrically in the residual cavity to allow internal drainage, removal of the percutaneous catheter, and avoidance of an external fistula. Follow-up CT demonstrated complete absence of the spleen (Fig. 3B). No endoscopic complications occurred. The patient was discharged tolerating tube feeds. CT scan 1 month later demonstrated signs of metastatic gastric cancer. The patient died of progressive metastatic disease 3 months later.

Intraoperative cholangiography using an endoscopic nasobiliary tube during a laparoscopic cholecystectomy

The goals of this report are to present the characteristics of biliary complications associated with laparoscopic cholecystectomies (LC) performed at a single center, and to evaluate the efficacy of intraoperative cholangiography (IOC) using an endoscopic nasobiliary tube (ENBT) during an LC in order to prevent biliary complications. A retrospective audit was conducted on a total of 657 patients who underwent either LC or open cholecystectomies (OC). There were 19 patients who developed bile duct injury (BDI; n = 9) or bile leakage (BL; n = 10) during an LC and were actively treated. After May of 1999, the patients with a higher risk of developing biliary complications were selected for preoperative placement of an ENBT, and IOC was performed. Intraoperative cholangiography using ENBT was performed on 93 (27.1%) out of 343 patients who underwent either LC or OC after May of 1999. An LC was performed in 335 cases (97.7%), and a conversion from an LC to OC was necessary in only three cases. Even though BDI never occurred, BL from the cystic duct and gallbladder bed were recognized in five cases. The selective use of IOC using ENBT may help to prevent BDI during LC, thereby expanding the indications for LC, while also reducing the rate of conversion to open procedures.

Extracorporeal shock wave lithotripsy for pancreatic and large common bile duct stones

Extraction of large pancreatic and common bile duct (CBD) calculi has always challenged the therapeutic endoscopist. Extracorporeal shockwave lithotripsy (ESWL) is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy. Pancreatic calculi in the head and body are targeted by ESWL, with an aim to fragment them to < 3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangiopancreatography (ERCP). In our experience, complete clearance of the pancreatic duct was achieved in 76% and partial clearance in 17% of 1006 patients. Short-term pain relief with reduction in the number of analgesics ingested was seen in 84% of these patients. For large CBD calculi, a nasobiliary tube is placed to help target the calculi, as well as bathe the calculi in saline - a simple maneuver which helps to facilitate fragmentation. The aim is to fragment calculi to < 5 mm size and clear the same during ERCP. Complete clearance of the CBD was achieved in 84.4% of and partial clearance in 12.3% of 283 patients. More than 90% of the patients with pancreatic and biliary calculi needed three or fewer sessions of ESWL with 5000 shocks being delivered at each session. The use of epidural anesthesia helped in reducing patient movement. This, together with the better focus achieved with newer third-generation lithotripters, prevents collateral tissue damage and minimizes the complications. Complications in our experience with nearly 1300 patients were minimal, and no extension of hospital stay was required. Similar rates of clearance of pancreatic and biliary calculi with minimal adverse effects have been reported from the centers where ESWL is performed regularly. In view of its high efficiency, non-invasive nature and low complication rates, ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.