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

The extracorporeal length of nasobiliary tube as a risk factor for nasobiliary tube migration

BACKGROUND AND AIM

Endoscopic nasobiliary drainage (ENBD) plays a crucial role in the treatment of acute cholangitis and obstructive jaundice. This research aimed to investigate the clinical characteristics and risk factors associated with nasobiliary drainage (NBD) tube migration.

METHODS

A retrospective single-center study was conducted, including all patients who underwent ERCP and placed an NBD tube between January 2022 and December 2023.

RESULTS

A total of 1077 patients were included in this study (mean age 59.8 years). Among these, 75 (7.0%) experienced NBD tube migration during their hospital stay. Univariate analysis showed that the maximum width of the bile duct, type of NBD tube, bile duct stricture, placement of a bile stent and/or pancreatic duct stent, and the extracorporeal length of NBD tube were correlated with NBD tube migration (p < 0.05). Multivariate regression analysis indicated that the type of NBD tube (p = 0.01 OR 1.9, 95% CI (1.16-3.13)) and the extracorporeal length of the NBD tube (p < 0.0001 OR 0.96, 95% CI (0.96-0.99)) were independent risk factors for NBD tube migration. Furthermore, it was found that when the extracorporeal length of the NBD tube was greater than 150 cm, the incidence of NBD tube migration was significantly lower than in the group with lengths less than 150 cm (p < 0.001).

CONCLUSION

NBD tube migration is not uncommon in clinical practice. The type of NBD tube and the extracorporeal length of the NBD tube were identified as independent risk factors for NBD tube migration. Ensuring that the extracorporeal length of the NBD tube is greater than 150 cm may reduce the incident of NBD tube migration.

Efficacy and safety of sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage for the treatment of hilar malignant biliary stricture: a retrospective cohort study

Background

The rising incidence of hilar malignant bile duct strictures poses challenges for diagnosis and treatment. While endoscopic treatment is essential for relieving obstruction, it carries a high risk of postoperative cholangitis. Sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may emerge as an effective strategy to mitigate these complications.

Objectives

This study aimed to evaluate the efficacy and safety of nasobiliary tube cutting after nasobiliary drainage versus conventional stent placement in reducing postoperative cholangitis in patients with hilar malignant biliary strictures.

Design

A retrospective cohort study.

Methods

From 2015 to 2023, 208 patients were divided into two groups: nasobiliary tube cutting group (n = 103) and conventional stent group (n = 105). The primary outcome was postoperative cholangitis, with secondary outcomes including drainage success, bilirubin reduction, re-interventions, complications, and hospital stay.

Results

Cholangitis occurred in 11.7% of the nasobiliary tube cutting group and 26.7% of the conventional stent group (p = 0.006). Successful drainage was achieved in 84 patients (81.6%) in the nasobiliary tube cutting group and 78 patients (74.3%) in the conventional stent group, with no statistically significant difference (p = 0.207). Patients whose total bilirubin reduction >50% within 7 days were significantly higher in the nasobiliary tube cutting group (48.5% vs 27.6%, p = 0.002). There were no significant differences between the groups in the number of endoscopic retrograde cholangiopancreatography procedures or re-interventions required (p > 0.05). Except for postoperative cholangitis, other postoperative complications were comparable between the groups (p > 0.05). The postoperative hospital stay was significantly longer in the nasobiliary tube cutting group, with a median duration of 10.0 (7.0, 14.0) days compared to 7.0 (5.5, 12.5) days in the conventional stent group (p = 0.024). Bismuth-Corlette Type IV was identified as an independent risk factor for cholangitis (OR = 3.207, 95%CI: 1.253-8.210, p = 0.015).

Conclusion

For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it may result in a prolonged postoperative hospital stay. Bismuth-Corlette Type IV is an independent risk factor for the development of postoperative cholangitis.

The assessment of postoperative cholangitis in malignant biliary obstruction: a real-world study of nasobiliary drainage after endoscopic placement of self-expandable metal stent

Objectives

Endoscopic retrograde cholangiopancreatography(ERCP) with endoscopic metallic biliary endoprosthesis(EMBE) serves as a crucial palliative treatment for advanced malignant biliary obstruction(MBO). While endoscopic nasobiliary drainage(ENBD) effectively reduces post-ERCP cholangitis (PEC) incidence, its impact on PEC in MBO patients is unclear. This study evaluates ENBD's effects on PEC in patients undergoing EMBE and identifies risk factors.

Methods

This retrospective cohort study at the First Hospital of Jilin University involved MBO patients who underwent EMBE from September 2011 to September 2022. Propensity score matching (PSM) was applied to minimize selection bias. Primary and secondary outcomes included the incidence and recovery rate/time of PEC, biliary drainage success, and hospitalization duration. Univariate, multivariate, and Lasso regression analyses identified independent risk factors.

Results

In this study of 1,008 patients, 730 were analyzed after PSM(365 each in the EMBE+ENBD and EMBE groups). No significant differences were observed in PEC incidence(10.7% vs 11.2%, p=0.9057) or recovery rates(48.7% vs 31.7%, p=0.1855). However, PEC recovery time was shorter in the EMBE+ENBD group(4.0 days [3.0, 6.0] vs 5.0 days [4.0, 7.5], p=0.0240), as was hospitalization duration(6.0 days [4.0, 8.0] vs 7.0 days [5.0, 10.0], p=0.0146), and a higher success rate of biliary drainage(54.0% vs 43.3%, p=0.0049). Tumor location(HR 1.10, 95% CI 1.00-1.20) and preoperative total bilirubin(HR 2.13, 95% CI 1.66-2.73) were identified as independent risk factors.

Conclusion

In this large-scale PSM study, ENBD did not reduce PEC incidence but expedited recovery and shortened hospital stays. Patients with hilar MBO of Bismuth III-IV or high preoperative bilirubin were more prone to PEC.

Evaluation of Clinical Indications of Three Treatments for Choledocholithiasis with Acute Cholangitis

Objective

This study aimed to assess the efficacy of Endoscopic Retrograde Cholangiopancreatography (ERCP), common bile duct exploration, and percutaneous transhepatic cholangiography combined with common bile duct exploration for treating choledocholithiasis with acute cholangitis, to guide management strategies.

Methods

A retrospective evaluation was conducted on a cohort of 283 inpatients diagnosed with choledocholithiasis and acute cholangitis at the affiliated hospital. Patients were categorized into three groups: Group A (ERCP group), Group B(common bile duct exploration group), and Group C(PTCD combine common bile duct exploration group.) Parameters such as hepatic function recovery, inflammation level control, blood loss, postoperative hospital duration, and postoperative complications were compared.

Results

All groups exhibited notable reductions in postoperative biochemical parameters including alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), total bilirubin (TBIL), and WBC (P < 0.05). Group A had the least blood loss(P < 0.05), and shortest hospital stay(P < 0.05), but a higher incidence of pancreatitis(P < 0.05), with a total of 8 cases occurred(7.3%). Group C had a shorter hospital stay compared to Group B(P < 0.05).

Conclusion

For patients with fewer and smaller common bile duct stones and milder symptoms, it is recommended to primarily choose endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST), and endoscopic nasobiliary drainage (ENBD), it procedures offer quicker recovery and cause minimal trauma. For patients with numerous, larger common bile duct stones but stable conditions, bile duct exploration is recommended. For those with severe conditions and significant inflammation, PTCD and common bile duct exploration are advised.

Efficacy of ultrasound-guided percutaneous transhepatic biliary drainage for acute obstructive suppurative cholangitis combined with septic shock

OBJECTIVES

This study aimed to investigate the efficacy of ultrasound-guided Percutaneous Transhepatic Biliary Drainage (PTCD) for the treatment of Acute Obstructive Suppurative Cholangitis (AOSC) combined with septic shock due to choledocholithiasis, and its effect on inflammatory factors.

METHODS

Clinical data of 86 patients with AOSC and septic shock admitted to our hospital between January 2019 and May 2021 were retrospectively analyzed and grouped according to different treatment methods. Among them, 43 patients who underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Nasobiliary Drainage (ENBD) were included in the Control Group (CNG), and 43 patients who underwent ultrasound-guided PTCD were included in the Study Group (SG).

RESULTS

The total effective rate in the SG (88.37%) was higher than that in the CNG (69.77%) (p < 0.05); after surgery, the serum inflammatory factors PCT, IL-6, TNF-α, CRP levels, liver function indicators such as TBIL, DBIL, AST, ALT levels, and stress response indicators including NPY, PGE2, 5-HT levels were reduced, and were lower in the SG than in the CNG (p < 0.05); postoperatively, CD3+, CD4+, and CD4+/CD8+ levels in the CNG were significantly lower than those before surgery (p < 0.05); Postoperatively, CD3+, CD4+, and CD4+/CD8+ levels in the SG were significantly higher than those in the CNG (p < 0.05); and the complication rate in the SG (6.98%) was lower than that in the CNG (25.58%) (p < 0.05).

CONCLUSIONS

Ultrasound-guided PTCD for AOSC combined with septic shock can facilitate the recovery of liver and immune functions with a low complication rate.

A Rare Case of Biliary Cryptococcosis Clinical Pharmacist Participation in Treatment and Pharmaceutical Care and Literature Review

Biliary cryptococcosis infection is extremely rare and difficult for preoperative diagnosis. We report a rare case of 61-year-old woman with biliary cryptococcal infection. To explore the general rule and case characteristics of biliary cryptococcal infection and provide a reference for future diagnosis and treatment, we consulted the PubMed database for reported biliary cryptococcal infection from 1985 to 2021. Including the present one, we collected 12 reports, among which half were male and five were younger than 18 years old. Clinical manifestations were mainly jaundice, while in vitro examination revealed bile duct dilatation and bile duct stenosis. In 8 cases (66.67%), symptoms improved or healed after antifungal treatment. Although preoperative misdiagnosis of cryptococcal infection is high, the antifungal treatment is quite effective. Thus, early accurate diagnosis can effectively improve the cure rate of biliary cryptococcosis infected patients.

The clinical effect of a strategy called transcystic gallbladder-preserving cholecystolithotomy based on endoscopic retrograde cholangiopancreatography for cholecystolithiasis: A retrospective study from a single center

Background

Choledocholithiasis complicated with cholecystolithiasis is a common disease. This study explores a novel strategy, called ERCP-based transcystic gallbladder-preserving cholecystolithotomy, for the simultaneous removal of common bile duct stones and gallbladder stones.

Methods

From December 2018 to June 2021, all patients with cholecystolithiasis and common bile duct stones who met the criteria for gallbladder preservation in our hospital were included in the study and prospectively followed up.

Results

We included 48 patients, including 20 patients with acute biliary pancreatitis. All patients successfully underwent ERCP to remove common bile duct stones. One patient had gallbladder perforation during gallbladder-preserving cholecystolithotomy. The guide wire successfully entered the gallbladder, and the transpapillary gallbladder metal-covered stent was successfully placed in 44 patients. The technical success rate was 91.67% (44/48). All stones were removed in 34 patients, for a clinical success rate of 77.27% (34/44). The total postoperative complication rate was 6.25% (3/48), with 2 cases of pancreatitis (4.17%) and 1 case of cholangitis (2.08%). Three patients were lost to follow-up. Among the 31 patients who were followed up for a mean of 27 months (6-40), 5 patients (16.13%) experienced gallstone recurrence. The recurrence rates at 12 months, 18 months, 24 months, 30 months and 36 months were 0%, 3.23%, 6.45%, 12.9%, and 16.13%, respectively.

Conclusion

For patients with cholecystolithiasis and common bile duct stones, ERCP-based transcystic gallbladder-preserving cholecystolithotomy without gallbladder incision can preserve gallbladder structure, and this procedure is safe and feasible for the protection of gallbladder function.Clinical trial registration: The study was registered in the Chinese Clinical Trial Registry, and the registry number is ChiCTR1900028006.

A single-center retrospective study comparing safety and efficacy of endoscopic biliary stenting only vs. EBS plus nasobiliary drain for obstructive jaundice

Purpose

Biliary drainage is an important modality for extrahepatic obstructive jaundice both in patients with palliative and resectable. Currently, endoscopic biliary drainage is preferred in clinical practice, including endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS), both of which have their own advantages and disadvantages. The purpose of our study was to compare the safety and efficacy of endoscopic biliary stenting (EBS) only vs. EBS plus nasobiliary drain for obstructive jaundice.

Methods

We consecutively reviewed patients with endoscopic biliary drainage in our institution from November 2014 to March 2021. Combined (ENBD plus stent) and single approach (EBS only) were defined as combined approach and single modality, respectively, and all eligible patients were divided into a combined approach group and a single modality group. We compared combined vs. single modality approaches to investigate whether there were statistical differences in liver chemistries, postoperative adverse events, and stent patency time.

Results

In 271 patients, a total of 356 times endoscopic biliary drainages were performed. All eligible patients were divided into the combined approach group (n = 74) and the single modality group (n = 271). The combined approach was associated with a lower incidence of postoperative cholangitis and bleeding and greater improvement in liver chemistries, although it was not statistically significant. However, it was superior to the single modality group in terms of hospital stay (12.7 ± 5.2 vs. 14.5 ± 7.9 days, p = 0.020 &lt; 0.05) and stent patency time (8.1 ± 3.9 vs. 4.3±2.7 months, p = 0.001 &lt; 0.05).

Conclusion

Endoscopic combined (ENBD plus stent) drainage is a more advantageous biliary drainage method that is characterized by more adequate biliary drainage, a lower incidence of postoperative adverse events, and longer effective biliary drainage time.

The efficacy and safety of balloon dilation for unresectable malignant biliary obstruction before placement of self-expanding metal stents

OBJECTIVE

To evaluate whether patients with malignant biliary obstruction (MBO) benefit from balloon dilation before the placement of a self-expanding metal stent (SEMS) for palliative biliary drainage.

METHODS

Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with SEMS placement for palliative management of MBO were retrospectively included. Comparative analyses of serum bilirubin levels, post-procedural adverse events, stent patency time, stent dysfunction, and patient survival were performed between the dilation and non-dilation groups.

RESULTS

A total of 221 patients underwent palliative endoscopic SEMS implantation for MBO from January 2014 to June 2018. Dilation significantly improved the percentage of serum bilirubin improvement (37.0% vs 14.3%, P = 0.001), with a decreasing trend in the incidence of post-procedural cholangitis (2.5% vs 7.8%, P = 0.075), while the rates of other complications such as pancreatitis and bleeding were not increased. The patency time of SEMS and patient survival did not significantly differ between patients with and without dilation. Patients had endoscopic nasobiliary drainage (ENBD) but not dilation showed similar short-term outcomes as patients underwent dilation but without ENBD.

CONCLUSIONS

Dilation with a small-caliber balloon catheter before the placement of SEMS is a safe and effective approach for MBO. Balloon dilation may improve the short-term efficacy of SEMS placement, while long-term outcomes are not obviously affected. The short-term effect of stricture dilation may be achieved by ENBD. Further studies are needed to confirm our results.