nasal drainage tube in treating refractory biliary stricture

Comparing of ERBD and ENBD in the treatment of refractory biliary stricture and stones

Plastic biliary stent usage(ERBD) in the treatment of refractory biliary stricture and stones

Conventional ERCP operation was performed, and appropriate plastic biliary stent was selected for drainage according to the conditions of gallstones and common bile duct.

The placement of the plastic stent should be selected in the dilated bile duct above the stone.

In order to facilitate the placement of the stent, the stenosis of the bile duct can be dilated first, and then it can be expanded step by step according to the size of the endoscope and the stent.

Determine the diameter of the applicator. The principle is that the larger the diameter, the better the drainage effect.

The sphincterotomy should be done routinely before the biliary duct plastic stent is placed.

Plastic stent placement can prevent postoperative complications of pancreatitis.

After the plastic stent is placed, the drainage effect of the stent is observed, and the endoscope can be withdrawn after confirming that the drainage effect is satisfactory.

Nasal drainage biliary stent usage (ENBD) in the treatment of refractory biliary stricture and stones

Operating methods of endoscopic nasal biliary drainage (ENBD) is through duodenal endoscope, to put the nasal bile duct tube at proper location, and to get the other end of the tube out from the patients’ nasal cavity. It is to achieve the effect of solving bile duct obstruction, lowering pressure in bile duct and doing the drainage. 

The treatment of refractory choledocholithiasis by ENBD was combined with ERCP to show the stone location. Insert zebra guide wire to the dilated bile duct above the lesion. The drainage tube was inserted along the guide wire. Further adjust the position of the nasal bile duct tube in the duodenum and stomach under X-ray. After proper fixation, drainage under continuous negative pressure was conducted and the drainage bag was connected. The biliary tract can be washed through the nasal tube. Take record daily in terms of bile drainage volume and clinical features. 

The duration of nasal drainage tube indwelling depends on the size of the stone, patient's tolerance to the drainage tube and the working time of the drainage tube. Postoperative re-examination can be performed by injecting contrast agent directly through the drainage tube, and the stones situation can be observed under X-ray. If the stone is found to break and dissolve, and if the maximum diameter of the stone is less than 13mm, choose stone retrieval basket and extraction balloons to remove the stones. 

ENBD has been used in clinical practice for over 20 years. The use of ENBD in the treatment of refractory choledocholithiasis can reduce biliary pressure and facilitate drainage. For patients with biliary tract infection, nasal biliary drainage can also reduce endotoxin and bacterial metabolites in human blood, thereby it could provide advantage conditions for subsequent treatment.

There are few relevant studies focusing on the change of stone size after ENBD. Some studies have confirmed that stones are observed to be smaller and softer after ENBD treatment for refractory choledocholithiasis. 

The common complications of ENBD include detachment, migration, obstruction of nasal tube, acute pancreatitis, and biliary tract infection. To make enhanced observation and careful nursing, positive education guidance for patients and timely effective treatment are solutions to prevent and cure the complications.

ERBD and ENBD Comparison 

The study confirmed that the ERBD group had an effective rate of 75.0%, while the ENBD group had an effective rate of 90.5%, which was significantly higher than the ERBD group. And the ENBD group had a shorter tube duration time than the ERBD group. The effective rate of the ENBD group to treat refractory choledocholithiasis was higher than that of the ERBD group. 

The advantage of ENBD treatment is that the nasal bile duct can keep the papilla open, prevent residual stone obstruction, and effectively prevent biliopancreatic reflux, thereby it reduces the pressure in the pancreatic duct and reduces the incidence of complications such as pancreatitis. 

Whether endoscopic drainage of plastic stents or endoscopic nasal biliary drainage, in the treatment of refractory common bile duct stones, it plays important supplementary role with ERCP. For patients with large stones or poor general condition who cannot tolerate long endoscopic surgery, it is safe and effective method to gain time for selective surgery. These two methods can be chosen singly or in combined use.