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

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

Ayman M.Soliman, MD;  Ahmed M. Awad, MD;

Yasser A. ElReheem, MD; Usama ElAttar,  FRCS Department of  General Surgery, Ain Shams University, Cairo, Egypt.

Abstract

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.

Key  words: Laparoscopic  cholecystectomy,  endoscopic  nasobiliary  tube drain,  bile duct injury.

Introduction:

Laparoscopic management of acute cholecystitis is a logical progression from elective      laparoscopic      cholecystectomy, but questions remain about its safety, cost effectiveness, and success rate.l Although laparoscopic  cholecystectomy  is  the procedure of choice in chronic cholecystitis, its use in acute cholecystitis may be associated with  higher  costs  and  complication   rates. Also, It is  not  known  which  patients  with

acute cholecystitis are likely to require conversion  to  open  cholecystectomy   based on  preoperative   data   or  if   a  cooling-off period with medical therapy can diminish inflammation and increase the chance of successfullaparoscopic cholecystectomy.2,3

Intraoperative    bile    duct    injury    and/ or     postoperative      bile     leakage     have been      considered      among      the      most serious complications of laparoscopic cholecystectomy   (LC),  resulting  in  chronic

morbidity and even mortality. The incidence has been reported to be 0.3-3.4% by several authors.4   The  risk  factors  predisposing  to bile duct injury or postoperative bile leakage include the presence of an accessory hepatic duct, the  anomalous  cystic duct confluence, and duct ofLuschka.3,4 Therefore, it is crucial to be aware of these anomalies prior to surgery to  help  prevent  bile  duct  injury.S Although there  are many  series that  show  the safety of laparoscopic cholecystectomy, the true incidence of bile duct injury is undoubtedly, most  bile  duct  injuries  occur  in  cases  of acute cholecystitis  and are not prevented by intraoperative   cholangiography.6   A  method to prevent bile duct injury is preoperative placement of an endoscopic  nasobiliary tube drain (ENBTD). ENBTD assisted LC; this technique  was first  proposed  by Uchiyama et al. in 2006 and was advocated  by several others   especially   for   situations   prone   to bile duct injury, such as acute cholecystitis, anticipated severe inflammation, and the presence  of bile  duct  anomalies.7  We have performed  ENBTD assisted LC for all cases in which acute cholecystitis ± bile duct anomalies as recognized preoperatively.

In this study we evaluate the surgical outcomes  of  laparoscopic  cholecystectomy for  cholecystitis  ± acute     complicated cholecystitis  ± presence  of  bile  duct anomalies.  Also,  to  highlight  the  role  and the  efficacy  of  ENBTD  assisted  LC  with regard to prevention of intraoperative and postoperative bile duct injury or leakage.

Patients and methods:

This  study  was  conducted   over  ninety six patients presented with acute calcular cholecystitis in Ain Shams University Hospitals (Egypt) and in Obeid Hospital, Armed Forces Hospital KingAbdulaziz Naval Base and Soliman Fakeeh Hospital (Saudi Arabia)   during  the  period  between  April

2009 to June 2011. Patients with acalculous cholecystitis   were   excluded.   For   patients with cholecystitis that was associated with organ or system dysfunction, a percutaneous cholecystostomy tube was inserted as an alternative to operating on high-risk  patients

and   thereby    converting    their    operation to   an   elective   procedure,   those   patients were also excluded. For all cases (acute ± complicated cholecystitis)  bile duct anatomy was  evaluated   by  (ERCP)  with  placement of an ENBTD. Figure(1,2) Endoscopic nasobiliary  tube  (ENBTD)  placement technique was as described by Soehendra8: Nasobiliary   catheter   was   applicated   over the guide wire passing through the biopsy channel of the endoscope and its tip was positioned above the bifurcation of the CBD without concomitant sphincterotomy  (except if  done  during    therapeutic  ERCP).  Guide wire was then withdrawn followed by the endoscope. After ensuring a free flow of bile from  the  external  end  of  ENBD  catheter, the  catheter  was rerouted  through  the  nose by a rail-road technique using a nasogastric tube which  passed transnasally;  and finally, the endoscopist passed his fingers into the patient's mouth to retrieve the transfer tube from the oropharynx to allow the nasobiliary tube to  be transferred  from  mouth to  nose. A cholangiogram  was repeated through the ENBD catheter to adequately visualize the biliary system and to confirm its position. Then ENBD catheter, while in position, was irrigated using  20 ml-60  ml of sterile  normal saline.

The ENBTD types are shown  in table 1. In this study we used (5,7 F straight or pigtailed tip ENTD tube, Olympus MS, long a, 4,9 side openings) Figure(3) Each case was carefully watched for post ENBTD pancreatitis. Laparoscopic   cholecystectomy   was performed using the standard 3- or 4-port technique one day after ENBTD application with/without intraoperative cholangiography (IOC).

As previously described, AC was defined when  the   patient   had  2  or  more  of  the following   clinical   and  operative   findings. The clinical factors  consisted  of: fever with a body temperature higher than 37.5°C, leukocytosis and right upper abdominal pain with  tenderness  continuous  for  more  than

48-hour duration despite medical treatment. Ultrasound    findings   included   gallbladder wall thickness (edema) of greater than 4 mm

Figure (1): Technique  of placement of endoscopic nasobiliary drainage  (ENBD).

(a) Endoscopic retrograde  cholangiopancreatography showed  lower bile duct stricture. (b) Deep cannulation with guidewire.

(c) Long a-type  ENBD tube was indwelling right intrahepatic duct. (d) The tube was advanced approximately 5 em or more.

(e) The scope was withdrawn into the stomach.

(f) The tube was adequately bent at the fornix of the stomach. (g) Air in the stomach  was aspirated.

(h) Adequate observation of the intragastric tube was possible.

Figure (2): Technique of conversion of the oral exit of the ENBTD  tube to nasal  exit a)An endoscopic catheter was cannulated into the bile duct. b) A guide catheter  was passed through the nasal opening to the pharynx. c) The catheter was withdrawn through  the  mouth.  d) The  ENBTD  tube was  fixed  to  the  guide  catheter.  e)  The guide  catheter  was    withdrawn  through the nose. f) The ENBTD  tube was fixed to keep it in place.

Table (1): Commercially available ENBD tubes.

A, angled; ENBD, endoscopic nasobiliary drainage; P, pigtailed; S, straight.

1-a, long a; Rl- a, reversed-long a.

d   

Figure (3): Endoscopic nasobiliary drainage tubes. (a) Pig-tailed tip without distortion, (b) Straight tip with contra a-distortion, (c) Straight tip with  a- distortion, (d) pig-tailed tip with a- distortion (a--c, Hanako; d, Olympus).

by     Abdominal    US    and    pericholecystic collection. The operative findings include severe         adhesion   to    an   adjacent    organ, distortion  of the  biliary anatomy, and gross

inflammation ofthe gallbladder serosa.

Complicated  cholecystitis is considered if hydrops,  empyema,  pericholecystic  abscess, or gangrene developed. Figure(4)

Figure (4):  A case of acute cholecystitis with thickened & inflammed gallbladder wall, with severe adhesion to an adjacent organ.

The  data  were  collected  from  all consecutive    ENBTD    assisted   LC   cases which  were  performed   in  our  institutions from January 2009 to June 2011 for each patient. Patients were analyzed for sixteen variables:  demographics  (age,  sex), preexisting comorbidities (diabetes mellitus, coronary artery disease, hyperlipidemia), preoperative    signs   and   symptoms   (right upper  quadrant  abdominal  pain,  nausea, fever); initial laboratory values (leukocytic count,  asparate  aminotransferase  [AST], alanine aminotransferase  [ALT], albumin, alkaline phosphatase  [ALP], bilirubin, amylase, lipase), and preoperative imaging (ultrasonography).  In the basic analysis, the mean and standard deviation for continuous variables  and the frequency  and proportion for  categorical  variables were  calculated  on the  entire  data set.  Univariate  analysis  for the histological diagnosis, the dependent variable  in this  study, was  performed  with Chi-square  analysis. The P value, odds ratio (OR), and 95% confidence interval (CI) were determined for each variable. The variables with a P value of 0.1 or less were selected for further multivariate analysis.

Results:

The study was carried on 36 men (37.5%) and 60 women  (62.5%),  with a mean  (SD) age of 57.9 years (range, 23-70 years). The diagnosis of the 96 patients who did LC included AC (n = 84 [87.5%]),  Complicated AC developed  in (n = 12 [12.5%])  patients. Complicated AC included empyema (n = 4), hydrops   (n = 2),  gangrenous   AC   (n = 1), perforation (n = 2) and pericholecystic abscess (n = 3).  The  preoperative  characteristics  of the patients according to the diagnosis are summarized in Table(2).

Results from univariate and multivariate analysis showed that 8 variables were associated  with  an  increased  risk  of developing AC. Table(3) listed the candidate predictors   in  the  final   logistic  regression model with their odds ratios (ORs) and corresponding  adjusted P values. American Society  of Anesthesiologists  score, presence of  respiratory  disease  or  chronic  liver disease, and history of a prevwus upper abdominal   operation   were  not  significant after multivariate analysis.

Table (2): Preoperative characteristics of the patients.

A total of 96 consecutive ENBTD assisted LCs were performed during the study period (male/female 36:60, median age 42±18years). To preoperatively  assess the biliary tract,  all patients underwent direct cholangiography (ERCP) which discoverd 5 cases of bile duct anomalies.  In total, we  performed  ENBTD

assisted LC for all cases. In terms of post ENBTD complication;  we experienced  a single  case  of  post  ENTD  pancreatitis   in the  case  of  cholecystitis  and  cholelithiasis. This event was conservatively managed with success and ENBTD assisted LC followed without bile duct injury 3 months later.

Table (3): Prediction for the development of acute cholecystitis.

Fro patients  with AC, the mean  operation time   was  longer   (P < .001)  and  the   mean blood loss during  LC was less (P < .001).

Discussion:

AC  is   associated   with   a   higher   grade of operative  difficulty and postoperative morbidity.  Therefore, considering the  many adverse influences on the patients  and the postoperative  outcomes,  it  is  desirable   to select the subgroup of patients  who are more prone  to develop  AC.7,8 Furthermore, for the patients  at high  risk of developing AC, it is better to operate  before AC develops.8  In the present  study, multiple  factors  are considered high  risk  for  AC  on  multivariate analysis. These  factors  include  comorbidities, such  as diabetes,   2  demographic  factors,   including age older than 51 years and male sex. Presence of  leukocytosis, peri-cholecystic collection, and elevated  liver enzymes are high predictor factors  for AC.

Also,    It has    been    reported    that    the

prevalence of the anomalous cystic duct confluence and  accessory  hepatic   duct  are

3.7-18  and  2.9-27%,  respectively.9   In  this

series  of 96 cases, the  incidences  are 0.6 and

2.0%, respectively.

MRCPisthemostusefulmodalitywhenthe cystic duct is occluded  or bile and pancreatic hi-ductal imaging is needed to diagnose pancreaticobiliary malunion.lO  Nevertheless, there  are  still  undoubtedly some  anomalies that  could  be  missed  by  all  available diagnostic modalities.ll  Many  authors  have

reported that  routine  roc reduces  risk  and

severity  of intraoperative common bile  duct injury and helps identify the site of injury.ll ,12

However,     injuries    to    accessory   hepatic ducts or anomalous cystic ducts cannot  be prevented by IOC  and in many cases of acute complicated or cholecystitis it is difficult  to

proceed  for   roc or  even  to  cannulate the

cystic duct which  is rarely  identified in these cases.   Therefore,  careful   dissection  of  the cystic  duct  and  artery  at  Calot's triangle is of  utmost  importance in the  recognition of bile duct anomalies which may necessitate proper  identification of bile duct anatomy.l3

This   study   has   shown   some   benefits   of the  preoperative placement of endonasal biliary  tube drainage  (ENBTD) to prevent intraoperative   bile    duct    injury    in   cases with   probable   bile  duct   anomalies.  There have been reports  advocating preoperative placement of ENTD tubes  or endoscopic nasogallbladder drainage (ENGBD) tubes for the same purpose in cases of acute cholecystitis complicated   by    severe    inflammation  or bile duct anomalies.l4 Recently,  some endoscopists have revealed that ENBTD is feasible and safe. Despite  established biliary drainage using a conventional duodenoscope, one   of   greatest    motivations   to   perform the   ENBTD   may   be  that   it  is  minimally invasive   even  for  critically   ill  patients.l4,15

The  merits  of  ENBTD  assisted  LC  as concluded  from this study  are as follows:

1.  ENBTD   has  the  advantage   of  not  only serving endoscopic drainage  of the biliary tree but delineating the biliary tree via cholangiography  and   detecting  biliary tract anomalies especially in patients  with difficulties in identifying the anatomy as the studied  group (acute cholecystititis).

2. roc can be repeated  intraoperatively using

the  ENBTD tube  if necessary,  especially if  the  surgeon   was  unable  to  visualize the cystic duct exterior because of severe inflammation,    adhesions     around     the Calot 's triangle, or biliary tract anomalies.

3.  It helped   to  distinguish  the   anomalous hepatic   duct  from   the   cystic   duct  and aberrant  cystic  duct  by  sensing  presence of  the  ENBTD  tube  during  LC  and  this is  stated  by  other  studies.  16,17  Kuroki and  his  associates similarly reported  the usefulness  of  this  technique to  identify the anatomy within the hepato-duodenal ligament.l8

4.   It  decreased the   rate  of  conversion to laparotomy in this study to zero even with presence  of both acute  inflammation and anomalies in the anatomy.

5.   The   cystic   duct   would   be  able   to   be distinguished from  the accessory hepatic duct accurately by using the ENBD tube. ERCP   and       subsequent       ENBTD    tube

for senous complications such as acute pancreatitis,    sepsis,    and    bleeding.l8    In this  series,  we  experienced   a  single  case of    post-intervention     pancreatitis.     Rates of  ERCP-related   morbidity   and   mortality have  been reported  to be 1-7 and  0.2-1%, respectively.  Uchiyama  et al. recommended the    preoperative    placement    of   ENBTD tubes  except  in  cases  of  anomalous  cystic duct     and  accessory  hepatic  duct type,  as the  bile duct  injuries  in his series  occurred in cases of anomaly types.l9 After weighing the  contribution  of ENBTD tube  placement to decreased intraoperative bile duct injury relative to its association with post ERCP pancreatitis,   ENBD   tube   placement   prior to LC may have successfully decreased the incidence  of  complications   during  LC  for acute or complicated cholecystitis.

In conclusion, male sex, age older than 51

years and diabetes increase the probability of developing AC in patients with symptomatic gallstones, and in suspected cases with acute or complicated  cholecystitis  ENBTD can be used safely to identify the bile duct and detect anomalies so we can avoid bile duct injuries in these cases.

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