Is there a place for the nasobiliary drain among stents for biliary drainage?

I read with great interest the European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline by Dumonceau et al. [1], describing the indications, choice of stents, and results in biliary stenting. Surprisingly, they did not mention endoscopic nasobiliary drainage (ENBD) as a choice among endoscopic measures. I think that, on the basis of a brief literature review, ENBD should find a place among the stents for biliary drainage.

Biliary drainage can be performed by means of endoscopic, percutaneous, or surgical methods, the endoscopic approach being the initial and most appropriate choice because of its less invasive nature and an acceptable complication rate [2] [3] [4]. Each modality of endoscopic drainage, internal stenting or external drainage (ENBD), has its own advantages and disadvantages [4]. However, there are many situations where one may be preferred over another or both may be used. A complementary approach may be logical in clinical practice, and the presence of different options strengthens the hand of the endoscopist.

ENBD was first described approximately four decades ago, for the temporary relief of biliary obstruction in patients with difficult-to-treat bile duct stones [5] [6]. Thereafter, its indications were expanded, to include closure of bile leaks with a variety of postoperative or traumatic causes [7] [8] [9], to prevent biliary obstruction [10] [11] [12], for drainage of biliary strictures [13], and for many diverse conditions. Although two randomized studies showed that there were no significant differences between ENBD and stenting for efficacy of drainage [14] [15], stenting is usually favored because of its comfort and suitability for long-term drainage. However, ENBD is still commonly used in some countries such as Japan [4] [13], and at many centers in Turkey it is selected especially for bile leaks, as described in previous reviews by myself and colleagues [16] [17], and where temporary drainage is indicated.

For example, ENBD in a case of acute cholangitis with thick bile allows continuous on-the-spot monitoring of bile color and output and can be done with or without stenting. At the Tokyo Consensus Meeting [4], Japanese faculties reported using internal drainage (3.7 %), ENBD (38.5 %), and both (61.5 %) for acute cholangitis.

The controversy over whether and how to perform preoperative biliary drainage in patients with hilar malignant strictures remains unsettled. Although, the recent ESGE Guideline [1] suggests stenting without mentioning ENBD in such cases, Japanese researchers recommend ENBD as the best method of preoperative drainage [13] [18] [19] [20] [21], because: (i) in the stenting group, in the study by Kawakami et al. [13], there was a high incidence of cholangitis (60 %) as a complication due to tube occlusion (a risk factor for postoperative liver failure); (ii) in the percutaneous drainage group, there were several cases of vascular injury and cancer dissemination. In contrast, the complications associated with ENBD were less frequent [13]. Unilateral ENBD of the future remnant lobe(s) is said to be an effective and suitable preoperative drainage method for perihilar cholangiocarcinoma even in patients with type III to IV tumors with a rare incidence of segmental cholangitis, despite lower success compared with type I and II tumors [18] [20] [21]. There is a consensus that the detailed anatomy of the biliary tree should be determined by multidetector computed tomography or magnetic resonance cholangiopancreatography to help elucidate the site of tube placement prior to endoscopic retrograde cholangiopancreatography (ERCP) [18] [19] [20] [21] [22].

In conclusion, I applaud the efforts of Dumonceau et al. [1] for preparing such a concise and enjoyable reading of this topic for endoscopists, and wonder about their thoughts on ENBD.

• References

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