Reply to Dr Ozaslan

I thank Dr. Ozaslan for his comments on the European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline dedicated to biliary stenting [1] [2]. In fact, endoscopic nasobiliary drainage was briefly mentioned in the Guideline in two instances:

• For the palliation of malignant hilar strictures, we proposed that the replacement of nonfunctioning plastic biliary stents by a nasobiliary drain or by a self-expandable metal stent should be considered if thick bile/pus was present. We acknowledged one of the advantages of nasobiliary drains in this setting, i. e. the capability for repeatedly flushing the bile ducts.

• For sealing bile leaks: we presented nasobiliary drainage as one of three endoscopic options available for that purpose. Other advantages of nasobiliary drainage in this particular indication were acknowledged, i. e., compared with stenting, the lack of need for repeat ERCP, and, compared with biliary sphincterotomy, the avoidance of short-term as well as long-term complications which affect 15 % of patients.

With regard to the preoperative drainage of malignant hilar strictures, nasobiliary drains may also be used as a substitute for stents but this option presents few advantages compared with plastic stents, except in the relatively uncommon case where cholangitis is present before ERCP. In our opinion, the disadvantages of nasobiliary drains prevail in this situation and include a lack of comfort for the patient and a risk of drain dislocation. Comfort may become a decisive factor if several drains have to be inserted or if the delay between endoscopic drainage and surgery is longer than a few days. As preoperative portal vein embolization is performed increasingly often to reduce liver dysfunction following extended hepatectomy, this further decreases the usefulness of nasobiliary drains in this particular indication [3].

Some of the factors cited above, in particular the perceived advantages and disadvantages of nasobiliary drains, may differ according to practice and, as mentioned by Dr Ozaslan, according to geographical area. This is why we always insist, in the Use of the guideline section, that ESGE guidelines “may not apply in all situations and should be interpreted in the light of specific clinical situations and resource availability.”

Finally, I thank Dr Ozaslan for his appreciation of our efforts and hope that ESGE guidelines will continue to help endoscopists in their day-to-day practice.

• References

• 1 Ozaslan E. Is there a place for the nasobiliary drain among stents for biliary drainage?. Endoscopy 2012; 44
• 2 Dumonceau JM, Tringali A, Blero D et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012; 44: 277-298
• 3 Hemming AW, Reed AI, Howard RJ et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003; 237: 686-691