Can Endoscopic Nasobiliary Drainage Involving Two Catheters Be Used to Treat Various Conditions?

The bile drainage methods in obstructive jaundice include percutaneous transhepatic biliary drainage (PTBD) via a percutaneous approach and endoscopic biliary drainage (EBD) through endoscopy. Due to the recent developments in endoscopic accessories and concerning reports on the disadvantages of PTBD, EBD is currently being favored over PTBD. Moreover, Kawakami et al. stated that PTBD is an invasive procedure and that it may be associated with not only early complications, such as tube dislocation, hemobilia, hepatic artery pseudoaneurysm, hepatic artery-bile duct fistula, and occlusion of the portal vein, but also late complications, such as catheter tract implantation metastasis caused by bile leakage. EBD can be classified as either external biliary drainage such as endoscopic nasobiliary drainage (ENBD) or internal biliary drainage such as endoscopic biliary stenting (EBS). Although EBS is associated with less discomfort and better quality of life, it does not permit the assessment of bile color and output, performance of cholangiography, and sampling of bile culture, and may also be associated with the risk of retrograde infection and stent occlusion, migration, and dislodgement. In contrast, ENBD, which can overcome these limitations, may lead to other problems, such as increased pharyngeal discomfort and nasal discharge, as well as intentional removal of the catheters by the patients. In the clinical setting, many cases of segmental cholangitis caused by an undrained segment of the bile duct cannot be resolved through only a single drainage, and studies of the effectiveness of multiple ENBD catheter placements have only included patients with hilar cholangiocarcinoma (CCA). Hence, the report on the use of double-ENBD catheters by Kim et al. in Clinical Endoscopy is groundbreaking and novel. They conducted a study on various patient groups, which included 20 patients with hilar CCA, 12 patients with hepatocellular carcinoma (HCC), three patients with anastomosis site stricture that developed after liver transplantation, and three patients with Mirizzi syndrome. However, after double-ENBD catheter insertion, statistically significant improvements were observed in liver function parameters such as total bilirubin, aspartate aminotransferase (AST), and alanine aminotransaminase, only in the patients with hilar CCA, but not in the patients with HCC, anastomosis site stricture, and Mirizzi syndrome. The lack of statistical significance in the other groups was attributed to the small number of patients in each group and the wide range of data. In fact, only three patients were included in the Mirizzi syndrome group, and the p-value was 0.312, despite a major Received: November 12, 2015 Revised: November 17, 2015 Accepted: November 17, 2015 Correspondence: Ho Gak Kim Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea Tel: +82-53-650-4041, Fax: +82-53-624-3281, E-mail: [email protected]