Severe acute cholangitis: the role of emergency nasobiliary drainage

The role of emergency endoscopic nasobiliary drainage (NBD) in the management of severe acute cholangitis was evaluated by comparing the outcome of 15 patients who underwent the procedure as an initial treatment with that of 20 patients who underwent emergency surgery. Biliary sepsis was successfully controlled without complication in all 15 patients by the insertion of a 7F nasobiliary catheter through a limited papillotomy. Subsequent definitive elective treatment included endoscopic stone clearance (n = 6), common duct exploration (n = 8), and bili-enteric reconstruction (n = 1). Among the 20 patients who had surgical treatment, cholecystectomy (n = 11), cholecystostomy (n = 1), and transhepatic intubation (n = 1) were done in addition to common duct exploration. Although patients undergoing endoscopic NBD were significantly older (75.3 years vs 60.1 years; p less than 0.05) and more jaundiced (total bilirubin, 120.3 mmol/L vs 70.4 mmol/L; p less than 0.05), comparable morbidity (40% vs 65%) and mortality (6.7% vs 20%) was observed. Initial endoscopic NBD provides a safe and effective therapeutic option for the management of fulminant biliary sepsis. Among patients with complicated ductal anatomy, endoscopic NBD should first be attempted because, when successful, definitive reconstruction may be performed on an elective basis. The value of its routine application for all patients, however, remains to be validated by further clinical studies.