Endoscopic nasobiliary tube placement was described 30 years ago [1]. The placement technique has not changed: after positioning the nasobiliary tube
within the biliary tree, the duodenoscope is withdrawn, leaving the tube exiting the
mouth; a transfer tube is passed transnasally; and finally, the endoscopist (or designee)
passes his or her 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.
Placing one’s fingers into the patient’s mouth can be dangerous, since the uncooperative
patient has a tendency to bite the doctor (or designee). Use of a bite block or mouthpiece
offers some protection [2]. A new technique is described that avoids this risk during nasobiliary tube transfer.
An 83-year-old woman on long-term warfarin therapy was recently diagnosed with pancreatic
head cancer. Because of worsening jaundice and acute abdominal pain, a computed tomography
(CT) scan was performed, which showed hemobilia and biliary obstruction. Endoscopic
retrograde cholangiopancreatography (ERCP) using moderate sedation showed blood emanating
from the papillary orifice. Cholangiography showed a distal biliary stricture and
filling defects consistent with clots. An expandable biliary stent was placed but
without ensuing biliary drainage due to clots. A nasobiliary tube was placed intrahepatically
but the transfer tube could not be introduced into either nare. A 5.4-mm endoscope
(Olympus GIF XP-160, Olympus, Center Valley, Pennsylvania, USA) was passed transnasally
to just above the epiglottis, retroflexed, and passed alongside the orally placed
nasobiliary tube out of the patient’s mouth ([Fig. 1], [Video 1]).
Fig. 1 The endoscope is passed transnasally and out of the mouth alongside the transorally
positioned nasobiliary tube. (The light source was turned off to facilitate photograph.)
Video
1 The small caliber endoscope is passed transnasally. The endoscope is retroflexed
and advanced alongside the nasobiliary tube which is positioned transorally. A basket
which is passed through the endoscope is used to grasp the proximal end of the nasobiliary
tube and the endoscope is withdrawn from mouth through the nose and then externally
along with the nasobiliary tube.
A pediatric stone retrieval basket was used to grasp the proximal end of the nasobiliary
tube ([Fig. 2], [Video 1]).
Fig. 2 The proximal portion of the nasobiliary tube has been grasped with a basket (arrow).
The endoscope and tube were withdrawn from the patient without difficulty. Minimal
self-limited nasal bleeding occurred ([Video 1]).
Transnasal endoscopy for nasobiliary tube transfer is useful for rare instances when
the transfer tube cannot be passed into the nares. More importantly, it avoids the
potential for endoscopist injury.
Competing interests: None
Endoscopy_UCTN_Code_TTT_1AO_2AK
