Self-made double-lumen jejunal tube for bile reinfusion and enteral nutrition after percutaneous transhepatic cholangial drainage

Abstract

BACKGROUND

Percutaneous transhepatic cholangial drainage (PTCD) effectively relieves biliary obstruction but inevitably causes bile loss, disrupting nutritional homeostasis and compromising gastrointestinal integrity.

AIM

To investigate whether a self-made double-lumen jejunal nutrition tube, which enables simultaneous bile reinfusion and enteral nutrition delivery, demonstrates superior clinical outcomes compared to conventional single-lumen enteral nutrition in PTCD patients.

METHODS

This retrospective cohort study enrolled 120 patients who underwent PTCD for obstructive jaundice between January 2019 and December 2023. Patients received either bile reinfusion combined with enteral nutrition via double-lumen jejunal tube (observation group, n = 60) or conventional single-lumen nasojejunal tube nutrition without bile reinfusion (control group, n = 60). Baseline characteristics were comparable between groups. Primary outcomes included nutritional biomarkers (serum albumin, prealbumin, transferrin) and gastrointestinal functional recovery indicators. Secondary outcomes encompassed complication rates, hospitalization duration, and patient satisfaction metrics.

RESULTS

The observation group demonstrated significantly superior outcomes across all parameters. Nutritional biomarkers showed greater improvement at postoperative days 7 and 14 (all P < 0.001). Gastrointestinal function recovery was markedly accelerated, with reduced time to first flatus (48.3 ± 8.2 hours vs 68.5 ± 12.3 hours, P < 0.001) and first defecation (72.1 ± 10.5 hours vs 96.8 ± 15.2 hours, P < 0.001). The observation group experienced a 60% relative reduction in overall complication rates (20.0% vs 50.0%, P = 0.015), 30% shorter hospital stays (10.2 ± 2.3 days vs 14.5 ± 3.1 days, P < 0.001), and significantly higher patient satisfaction scores (8.5 ± 1.2 vs 6.3 ± 1.5, P < 0.001). Multivariate analysis identified bile reinfusion as an independent predictor of treatment success (adjusted odds ratio = 9.45, 95% confidence interval: 2.31-38.67, P = 0.002).

CONCLUSION

The self-made double-lumen jejunal nutrition tube with integrated bile reinfusion significantly enhances nutritional recovery, accelerates gastrointestinal function restoration, reduces complications, shortens hospitalization, and improves patient-centered outcomes in PTCD patients, offering a safe and practical approach for postoperative management.

Key Words: Self-made double-lumen jejunal nutrition tube; Percutaneous transhepatic cholangial drainage; Biliary juice reinfusion; Enteral nutrition support; Application effect; Safety

Core Tip: After percutaneous transhepatic cholangial drainage, bile is usually lost externally, which may compromise nutrition and gastrointestinal recovery. This study evaluated a self-made double-lumen jejunal nutrition tube that permits bile reinfusion while delivering enteral nutrition. Compared with conventional single-lumen feeding, this approach improved serum nutritional markers, hastened bowel function recovery, lowered complication rates, shortened hospital stay and increased patient satisfaction. The results support double-lumen jejunal tube–based bile reinfusion as a feasible and effective strategy for postoperative care in percutaneous transhepatic cholangial drainage patients.

INTRODUCTION

Biliary obstruction represents a prevalent clinical syndrome substantially affecting patient health and life quality. This condition frequently results from diverse hepatobiliary pathologies, including choledocholithiasis, biliary inflammation, and hepatobiliary malignancies. Therapeutic management has persistently challenged practitioners, as this condition produces severe hyperbilirubinemia and triggers systemic complications encompassing hepatic dysfunction, hemostatic abnormalities, and systemic inflammatory response syndrome[1].

Among therapeutic modalities, percutaneous transhepatic cholangial drainage (PTCD) has established itself as a vital interventional technique offering efficient biliary obstruction relief, bilirubin reduction, and hepatic function restoration[2]. Over 2500 PTCD interventions are annually conducted in the Netherlands, primarily for biliary obstruction management following unsuccessful endoscopic cannulation[3,4].

Bile depletion following PTCD can result in detrimental outcomes encompassing malnutrition, compromised lipid absorption, gastrointestinal dysfunction, and elevated infection risk. Bile functions critically in fat emulsification and absorption of fat-soluble vitamins while maintaining intestinal flora stability[5]. Traditional management involved external bile drainage with discarding of bile, leading to loss of these physiological functions.

Recent studies have explored innovative approaches to restore bile’s physiological role. A double-lumen biliary-enteric tube study assessed its effectiveness for enteral nutrition in malignant obstructive jaundice patients[6]. Studies have also demonstrated the beneficial effects of bile reinfusion on bile acid metabolism and gut microbiota[7]. However, evidence remains limited regarding the systematic application of bile reinfusion combined with enteral nutrition support in PTCD patients. This study aimed to evaluate the clinical efficacy and safety of a self-made double-lumen jejunal nutrition tube that enables simultaneous bile reinfusion and enteral nutrition delivery.

MATERIALS AND METHODS

Study design

This was a retrospective cohort study conducted to evaluate the clinical efficacy and safety of a self-made double-lumen jejunal nutrition tube for biliary juice reinfusion combined with enteral nutrition support in patients undergoing PTCD.

Patient selection and enrollment

We screened all patients who underwent PTCD for obstructive jaundice at our institution between January 2019 and December 2023. Inclusion criteria comprised: (1) Age ≥ 18 years; (2) Confirmed obstructive jaundice due to benign or malignant biliary disease (bile duct stones, biliary infections, or biliary tumors); (3) Successful PTCD completion; (4) Requirement for enteral nutrition support ≥ 7 days postoperatively; and (5) Complete medical records available. Exclusion criteria included: (1) Severe comorbidities (heart failure, chronic obstructive pulmonary disease, or renal failure) that could significantly confound outcomes; (2) Prior gastrointestinal surgery potentially affecting nutrient absorption; (3) Incomplete medical records or loss to follow-up within 30 days; and (4) Transfer to other facilities before nutritional support protocol completion.

A total of 120 patients met inclusion criteria and were divided into two groups based on the postoperative nutritional support method. The intervention group (n = 60) received bile reinfusion combined with enteral nutrition via self-made double-lumen jejunal nutrition tube, while the control group (n = 60) received enteral nutrition via traditional single-lumen nasojejunal tube without bile reinfusion. The nutritional support method was determined by attending physician clinical assessment and institutional protocol evolution, with single-lumen tubes representing standard practice before June 2021 and double-lumen tubes adopted thereafter.

Standardization of perioperative care

To ensure comparability between groups and minimize potential temporal confounding, our institution maintained rigorously standardized perioperative care protocols throughout the entire study period (2019-2023). These protocols included: (1) Consistent PTCD procedure techniques performed by the same team of experienced interventional radiologists using standardized ultrasound and fluoroscopic guidance; (2) Uniform antibiotic prophylaxis regimens following institutional guidelines with no changes during the study period; (3) Standardized pain management approaches using identical analgesic protocols; and (4) Consistent basic nutritional assessment procedures for all patients. Nursing care protocols remained unchanged throughout the study period, encompassing standardized wound care, catheter management, vital sign monitoring frequencies, and patient education procedures. Discharge criteria were uniform and based exclusively on objective clinical parameters: Resolution of jaundice (total bilirubin < 3 mg/dL), stable liver function tests (alanine aminotransferase and aspartate aminotransferase < 2 × upper limit of normal), adequate tolerance of enteral nutrition (ability to receive at least 70% of prescribed nutrition without significant complications), absence of infection (normal temperature and white blood cell count), and demonstrated ability to perform basic self-care activities. A comprehensive review of institutional records confirmed that no major changes occurred in surgical team composition, equipment upgrades, or hospital policies during 2019-2023 that would systematically affect patient outcomes. The introduction of the double-lumen jejunal tube represented the primary and intentional intervention change, implemented as a structured quality improvement initiative with careful documentation and prospective monitoring of outcomes.

Self-made double-lumen jejunal nutrition tube

The self-made double-lumen jejunal nutrition tube was specifically designed to enable simultaneous bile reinfusion and enteral nutrition delivery. The device featured an outer diameter of 3.5 mm (10.5 Fr) and contained two inner lumens: One measuring 1.5 mm for nutrition delivery and another measuring 1.0 mm for bile reinfusion. The tube was constructed from medical-grade silicone to ensure biocompatibility and durability. With a total length of 120 cm, the tube was designed for placement with the distal tip positioned 20-30 cm beyond the ligament of Treitz to ensure optimal nutrient absorption and bile reinfusion into the jejunum. Each tube was custom-manufactured by the hospital’s medical device department under strictly controlled sterile conditions to maintain the highest safety standards.

PTCD procedure

All patients underwent PTCD under local anesthesia, with the procedure performed by experienced interventional radiologists using both ultrasound and fluoroscopic guidance to ensure precision and safety. The procedure began with the insertion of a guidewire into the obstructed bile duct through percutaneous puncture under imaging guidance. Following successful guidewire placement, the tract was carefully dilated to accommodate the drainage catheter. An 8-10 French drainage catheter was then placed to establish biliary decompression. Initially, bile was drained into an external sterile collection system, allowing for assessment of bile characteristics and volume before implementing the reinfusion protocol in the observation group.

Biliary juice reinfusion protocol

For patients in the observation group, a comprehensive biliary juice reinfusion protocol was implemented to restore the physiological functions of bile while maintaining strict safety standards. Bile was collected in a sterile external drainage bag equipped with an inline 0.45 μm filter to provide initial particle removal during collection. The volume of bile collected from the previous 4-hour period was measured and prepared for reinfusion. To ensure patient safety and prevent potential complications, all collected bile underwent double filtration through sequential 0.45 μm and 0.22 μm filters to remove particulate matter, debris, and potential contaminants. Before each reinfusion, quality control measures included visual inspection of the filtered bile for any signs of blood contamination or unusual debris; any bile that appeared contaminated was immediately discarded and not used for reinfusion. The filtered bile was then administered through the dedicated bile lumen of the double-lumen tube over a 30-minute period to allow gradual reintroduction into the digestive system. This reinfusion process was performed four times daily, maintaining a consistent schedule to optimize bile’s physiological role in digestion and absorption.

Enteral nutrition protocol

Both groups received enteral nutrition support following a standardized protocol designed to meet their nutritional requirements while promoting gastrointestinal tolerance. A standard polymeric formula with a caloric density of 1.0 kcal/mL was used for all patients. Enteral nutrition was initiated at a conservative rate of 20 mL/hour to allow gastrointestinal adaptation and minimize the risk of feeding intolerance. The infusion rate was then gradually increased over a 3-day period to reach the target rate of 50-80 mL/hour, depending on individual patient tolerance and nutritional requirements. The target daily caloric intake was set at 25-30 kcal/kg/day to meet the metabolic demands of postoperative recovery and healing. In the observation group, nutrition was delivered continuously via the dedicated nutrition lumen of the double-lumen tube using a calibrated feeding pump to ensure accurate and consistent delivery. In the control group, the same nutritional formula and delivery parameters were applied through the traditional single-lumen nasojejunal tube. The minimum duration of enteral nutrition support was 7 days, though it was continued beyond this period until patients achieved adequate oral intake, defined as the ability to consume more than 50% of their daily nutritional needs through the oral route.

Outcome measures

Primary outcomes: The primary outcomes of this study focused on two critical aspects of postoperative recovery. Nutritional status and gastrointestinal function. Nutritional status was assessed through measurement of three key serum biomarkers at three time points: Baseline (postoperative day 0), day 7, and day 14. These biomarkers included serum albumin (g/L, with a normal reference range of 35-50 g/L), prealbumin (mg/L, normal range 200-400 mg/L), and transferrin (mg/L, normal range 2.0-3.6 mg/L). To ensure consistency and accuracy, all blood samples were collected at 6:00 am after an overnight fasting period, and analyses were performed using standardized laboratory protocols.

Gastrointestinal function recovery was evaluated using multiple clinically relevant parameters. Time to first flatus was recorded in hours from the completion of the PTCD procedure, representing an important indicator of bowel motility restoration. Similarly, time to first defecation was documented in hours from the end of the procedure, reflecting more complete recovery of gastrointestinal function. A comprehensive gastrointestinal symptom score was developed and applied to quantify patient symptoms on a 0-10 scale, with higher scores indicating more severe symptoms. This composite score incorporated five symptom domains: Nausea (scored 0-2), vomiting (scored 0-2), abdominal pain (scored 0-3), bloating (scored 0-2), and diarrhea (scored 0-1). Additionally, the time to tolerating oral intake was recorded in days, representing an important milestone in the transition from enteral to oral nutrition.

Secondary outcomes: Secondary outcomes were designed to provide a comprehensive assessment of safety, clinical efficiency, and patient-centered results. Complications were monitored daily throughout the hospitalization period and categorized into several distinct types. Bile leakage at the PTCD site was carefully monitored through clinical assessment and, when indicated, imaging studies. Infectious complications were classified into drainage site infections and systemic infections or sepsis, with diagnoses based on clinical criteria and laboratory confirmation. Nutrition tube-related complications included blockage requiring intervention, tube displacement necessitating repositioning or replacement, and aspiration events. Other adverse events such as bleeding episodes and electrolyte imbalances were also documented and managed according to standard protocols.

Hospital stay indicators provided important information about the clinical efficiency and economic impact of the intervention. Total hospital stay was calculated as the number of days from initial admission to final discharge. Postoperative hospital stay, representing the period from PTCD completion to discharge, was separately recorded to specifically assess the recovery period following the intervention. For patients requiring intensive care, intensive care unit (ICU) stay duration was documented in days. Finally, unplanned readmissions within 30 days of discharge were recorded as an indicator of treatment durability and potential delayed complications.

Patient satisfaction was assessed at the time of discharge using a comprehensive 11-item questionnaire. Each item was scored on a 0-10 Likert scale, with higher scores indicating greater satisfaction. The questionnaire covered multiple domains of the patient experience, including overall satisfaction with care, satisfaction with nutritional support provided, effectiveness of symptom management, perceived recovery pace, comfort level during hospitalization, adequacy of information provided about their condition and treatment, quality of staff interactions, effectiveness of pain management, quality of postoperative care, satisfaction with the hospital environment, and satisfaction with arrangements for follow-up care. This multi-dimensional approach to patient satisfaction assessment provided a holistic understanding of the patient experience beyond purely clinical outcomes.

Data collection

Medical record review was conducted systematically by two independent researchers who were trained in the use of standardized data extraction forms specifically designed for this study. All relevant clinical data, laboratory results, procedural details, and outcome measures were extracted from electronic medical records and nursing documentation. To ensure data accuracy and reliability, any discrepancies identified between the two independent reviewers were resolved through consensus discussion. In cases where consensus could not be reached, a third senior researcher was consulted to make the final determination. To protect patient privacy and comply with ethical requirements, all data were de-identified prior to entry into the study database and analysis, with patients assigned unique study identification numbers that could not be traced back to individual identities.

Statistical analysis

Statistical analysis was performed using SPSS version 26.0 statistical software (IBM Corp., Armonk, NY, United States). Continuous variables were presented as mean ± SD and were compared between groups using independent samples t-tests after confirming normal distribution through the Shapiro-Wilk test. For variables that did not meet the assumption of normal distribution, the non-parametric Mann-Whitney U test was employed as an alternative. Categorical variables were presented as n (%) and were compared between groups using the χ² test. When the expected cell frequency was less than 5 in any cell of a contingency table, Fisher’s exact test was used instead of the χ² test to ensure statistical validity. Throughout all analyses, a two-tailed P value of less than 0.05 was considered to indicate statistical significance. To assess the adequacy of the sample size for detecting clinically meaningful differences, a post-hoc power analysis was conducted, which confirmed that the study achieved greater than 80% power for detecting the observed differences in primary outcomes, thereby validating the robustness of the study findings.

RESULTS

Patient characteristics

A total of 120 patients were included in the final analysis, with 60 patients in each group. The mean age was 58.2 ± 6.5 years in the observation group and 58.9 ± 7.0 years in the control group. No significant differences were found between the two groups in terms of demographic characteristics, baseline nutritional status, liver function tests, or disease etiology (Table 1). This comparability confirms the validity of comparing outcomes between the two groups.

Table 1 Baseline characteristics of study patients, mean ± SD/n (%).

Characteristic	Observation group (n = 60)	Control group (n = 60)	Test statistic	P value
Demographics
Age (years)	58.2 ± 6.5	58.9 ± 7.0	t = 0.40	0.693
Gender (male/female)	34/26	32/28	χ2 = 0.07	0.795
BMI (kg/m2)	23.5 ± 3.0	23.2 ± 2.8	t = 0.42	0.678
Baseline nutritional status
Serum albumin (g/L)	32.1 ± 3.2	31.8 ± 3.5	t = 0.35	0.731
Prealbumin (mg/L)	180 ± 25	178 ± 28	t = 0.30	0.767
Transferrin (mg/L)	2.0 ± 0.3	1.9 ± 0.4	t = 0.98	0.332
Liver function tests
Total bilirubin (μmol/L)	280 ± 50	275 ± 45	t = 0.42	0.674
Direct bilirubin (μmol/L)	180 ± 30	175 ± 35	t = 0.62	0.539
ALT (U/L)	120 ± 20	118 ± 22	t = 0.38	0.703
AST (U/L)	110 ± 18	108 ± 20	t = 0.42	0.677
Disease etiology
Benign biliary disease	30 (50.0)	28 (46.7)	χ2 = 0.07	0.796
Malignant biliary disease	30 (50.0)	32 (53.3)	χ2 = 0.07	0.796
Comorbidities
Hypertension	20 (33.3)	22 (36.7)	χ2 = 0.07	0.786
Diabetes mellitus	16 (26.7)	14 (23.3)	χ2 = 0.09	0.766
Chronic kidney disease	6 (10.0)	4 (6.7)	Fisher’s	1.000

BMI: Body mass index; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.

Nutritional status outcomes

Serum nutritional markers showed significant improvement in the observation group compared to the control group at both postoperative day 7 and day 14 (Table 2). While both groups began with similar baseline serum albumin levels (32.1 g/L vs 31.8 g/L, P = 0.731), divergence became apparent early in the recovery period. The observation group demonstrated significantly higher albumin levels at day 7 (36.5 g/L vs 34.2 g/L, P = 0.005), with this advantage becoming more pronounced by day 14 (39.8 g/L vs 36.1 g/L, P < 0.001). Remarkably, the observation group had achieved near-normal albumin levels by the two-week mark, indicating more complete nutritional restoration. Prealbumin levels followed a similar trajectory, with the observation group exhibiting significantly higher values at both day 7 (215 mg/L vs 195 mg/L, P = 0.003) and day 14 (245 mg/L vs 210 mg/L, P < 0.001). Transferrin recovery mirrored this pattern, showing superior improvement in the observation group at day 7 (2.4 mg/L vs 2.1 mg/L, P = 0.004) and day 14 (2.7 mg/L vs 2.3 mg/L, P < 0.001). The convergence of evidence across these three distinct nutritional biomarkers consistently demonstrates that biliary juice reinfusion combined with enteral nutrition significantly enhances nutritional recovery compared to enteral nutrition alone, likely through restoration of physiological bile functions essential for nutrient absorption and metabolism.

Table 2 Nutritional status indicators at different time points, mean ± SD.

Indicator	Time point	Observation group (n = 60)	Control group (n = 60)	t-value	P value
Serum albumin (g/L)	Baseline (day 0)	32.1 ± 3.2	31.8 ± 3.5	0.35	0.731
	Postoperative day 7	36.5 ± 2.8	34.2 ± 3.1	3.04	0.005
	Postoperative day 14	39.8 ± 2.5	36.1 ± 3.2	5.01	< 0.001
Prealbumin (mg/L)	Baseline (day 0)	180 ± 25	178 ± 28	0.30	0.767
	Postoperative day 7	215 ± 22	195 ± 26	3.24	0.003
	Postoperative day 14	245 ± 20	210 ± 28	5.67	< 0.001
Transferrin (mg/L)	Baseline (day 0)	2.0 ± 0.3	1.9 ± 0.4	0.98	0.332
	Postoperative day 7	2.4 ± 0.3	2.1 ± 0.4	3.28	0.004
	Postoperative day 14	2.7 ± 0.2	2.3 ± 0.4	4.89	< 0.001

Gastrointestinal function recovery

The observation group demonstrated significantly faster recovery of gastrointestinal function across all measured parameters (Table 3). Recovery of bowel motility, as indicated by time to first flatus, was substantially accelerated in the observation group, occurring at 48.3 ± 8.2 hours compared to 68.5 ± 12.3 hours in controls (P < 0.001), representing a 29.5% reduction. This advantage extended to complete bowel function restoration, with first defecation occurring at 72.1 ± 10.5 hours vs 96.8 ± 15.2 hours (P < 0.001), a 25.5% improvement. Beyond functional recovery, patients in the observation group also experienced significantly milder gastrointestinal symptoms, scoring 3.2 ± 1.1 compared to 5.8 ± 1.4 in controls (P < 0.001), and were able to tolerate oral intake earlier (4.2 ± 1.0 days vs 6.0 ± 1.5 days, P < 0.001). These consistent improvements across multiple indicators of gastrointestinal function strongly suggest that bile reinfusion promotes physiological digestive processes and accelerates postoperative recovery.

Table 3 Gastrointestinal function recovery indicators, mean ± SD.

Indicator	Observation group (n = 60)	Control group (n = 60)	Test statistic	P value
Time to first flatus (hours)	48.3 ± 8.2	68.5 ± 12.3	t = 7.56	< 0.001
Time to first defecation (hours)	72.1 ± 10.5	96.8 ± 15.2	t = 7.32	< 0.001
GI symptom score (0-10)1	3.2 ± 1.1	5.8 ± 1.4	t = 8.12	< 0.001
Time to oral intake (days)	4.2 ± 1.0	6.0 ± 1.5	t = 5.53	< 0.001
Time to full oral diet (days)	6.8 ± 1.2	9.5 ± 1.8	t = 6.80	< 0.001
Bowel sound recovery (hours)	36.5 ± 6.8	54.2 ± 9.1	t = 8.51	< 0.001

¹Gastrointestinal symptom score assessed on postoperative day 5.

GI: Gastrointestinal.

Complications

The observation group experienced significantly fewer complications compared to the control group, with an overall complication rate of 20.0% vs 50.0% (P = 0.015), representing a 60% relative reduction (Table 4). Analysis by complication category revealed multiple areas of advantage for the observation group. PTCD-related complications included significantly lower rates of bile leakage (6.7% vs 20.0%, P = 0.045), which may be attributed to maintained bile flow dynamics with reinfusion. Infectious complications were substantially reduced, with total infections occurring in 10.0% of the observation group compared to 30.0% of controls (P = 0.037), possibly due to bile’s antimicrobial properties and preservation of intestinal barrier integrity. Nutrition tube-related complications also favored the observation group, particularly tube blockage, which occurred in only 3.3% vs 16.7% (P = 0.035), likely reflecting the advantages of the double-lumen design. Additionally, electrolyte imbalance was less frequent in the observation group (6.7% vs 20.0%, P = 0.045), consistent with bile salt reabsorption restoring electrolyte homeostasis. These findings demonstrate that the double-lumen jejunal nutrition tube approach not only improves clinical outcomes but also substantially enhances patient safety.

Table 4 Postoperative complications, n (%).

Complication type	Observation group (n = 60)	Control group (n = 60)	χ2/Fisher’s1	P value
PTCD-related
Bile leakage	2 (6.7)	6 (20.0)	χ2 = 4.04	0.045
Catheter dislodgement	1 (3.3)	3 (10.0)	Fisher’s	0.301
Infectious
Drainage site infection	2 (6.7)	5 (16.7)	Fisher’s	0.214
Systemic infection/sepsis	1 (3.3)	4 (13.3)	Fisher’s	0.152
Total infections	3 (10.0)	9 (30.0)	χ2 = 4.32	0.037
Nutrition tube-related
Tube blockage	1 (3.3)	5 (16.7)	Fisher’s	0.035
Tube displacement	0 (0.0)	2 (6.7)	Fisher’s	0.150
Aspiration pneumonia	0 (0.0)	1 (3.3)	Fisher’s	0.313
Other complications
Wound infection	1 (3.3)	4 (13.3)	Fisher’s	0.152
GI bleeding	0 (0.0)	2 (6.7)	Fisher’s	0.150
Electrolyte imbalance	2 (6.7)	6 (20.0)	χ2 = 4.04	0.045
Recurrent jaundice	1 (3.3)	4 (13.3)	Fisher’s	0.152
Overall
Total patients with ≥ 1 event	6 (20.0)	15 (50.0)	χ2 = 5.93	0.015

¹Fisher’s exact test used when expected cell frequency < 5.

PTCD: Percutaneous transhepatic cholangial drainage; GI: Gastrointestinal.

Hospital stay outcomes

The observation group demonstrated significantly shorter hospitalization across multiple measures, reflecting the combined benefits of improved nutrition, faster gastrointestinal recovery, and reduced complications (Figure 1). Mean total hospital stay was 10.2 ± 2.3 days in the observation group compared to 14.5 ± 3.1 days in controls (P < 0.001), representing a clinically meaningful 30% reduction. Among the 66 patients (55%) requiring ICU admission due to the severity of their condition and postoperative complications, the observation group (n = 33) had substantially shorter ICU stays (1.2 ± 0.8 days vs 2.5 ± 1.2 days, P = 0.002) compared to the control group (n = 33).

Figure 1 Hospital stay duration comparison. Mean hospital stay duration (days) in observation group (n = 60) vs control group (n = 60). The observation group demonstrated significantly shorter total hospital stay (10.2 days vs 14.5 days), postoperative stay (9.5 days vs 13.8 days), and intensive care unit stay (1.2 days vs 2.5 days) compared to controls (all P < 0.05). Data represent mean values with error bars indicating standard deviation. ICU: Intensive care unit.

Patient satisfaction

Patient satisfaction was significantly higher in the observation group across all assessed domains, demonstrating that the clinical benefits translated into superior patient experience (Figure 2). Overall satisfaction scores reached 8.5 ± 1.2 in the observation group compared to 6.3 ± 1.5 in controls (P < 0.001), representing a 35% improvement.

Figure 2 Patient satisfaction scores at discharge. Comparison of mean satisfaction scores (0-10 scale) between observation group (n = 60) and control group (n = 60) across four domains: Overall satisfaction, nutritional support, comfort level, and pain management. The observation group showed significantly higher satisfaction in all domains (8.5 vs 6.3, 8.8 vs 6.5, 8.6 vs 6.4, and 8.1 vs 5.8, respectively; all P < 0.001), indicating superior patient experience with the double-lumen jejunal nutrition tube approach. Values are mean ± SD.

Predictors of treatment success

For the outcome of treatment success, the logistic regression model exhibited robust predictive performance [area under the curve = 0.84, 95% confidence interval (CI): 0.73-0.95]. Bile reinfusion demonstrated the strongest independent association with treatment success [adjusted odds ratio (aOR) = 9.45, 95%CI: 2.31-38.67, P = 0.002], indicating that patients receiving this intervention had nearly 10-fold higher odds of achieving successful treatment outcomes after controlling for baseline differences. Higher baseline prealbumin levels also independently predicted treatment success (aOR = 1.02 per 10 mg/L increase, 95%CI: 1.00-1.04, P = 0.043), reflecting the importance of baseline nutritional reserve. Conversely, presence of three or more comorbidities significantly reduced odds of treatment success (aOR = 0.23, 95%CI: 0.06-0.88, P = 0.032), highlighting the challenge of managing complex patients regardless of nutritional intervention strategy (Figure 3).

Figure 3 Forest plot showing adjusted odds ratios for factors associated with treatment success. The plot displays three variables and their relationship with treatment outcomes. Bile reinfusion [adjusted odds ratio (aOR) = 9.45, 95% confidence interval (CI): 2.31-38.67, P = 0.002] and prealbumin per 10 mg/dL increase (aOR = 1.02, 95%CI: 1.00-1.04, P = 0.043) were associated with favorable treatment success (shown in blue), while having ≥ 3 comorbidities (aOR = 0.23, 95%CI: 0.06-0.88, P = 0.032) was associated with unfavorable treatment success (shown in orange). The x-axis presents adjusted ORs on a logarithmic scale, with the vertical dashed line at 1.0 representing no effect. Error bars indicate 95%CIs. aOR: Adjusted odds ratio; CI: Confidence interval.

DISCUSSION

The superior outcomes observed in the bile reinfusion group can be directly attributed to restoration of bile’s critical physiological functions through several interconnected mechanisms. First, the significant elevation in serum albumin, prealbumin, and transferrin levels in the observation group directly reflects restored lipid absorption and enhanced bioavailability of fat-soluble vitamins (A, D, E, and K) through bile’s essential emulsification function[8,9]. Bile acids facilitate micelle formation in the intestinal lumen, which is absolutely necessary for efficient absorption of dietary fats and fat-soluble nutrients. Second, the markedly reduced time to first flatus and defecation observed in our study is entirely consistent with bile acids’ well-established prokinetic effects on gastrointestinal motility[10,11]. Bile acids, particularly secondary bile acids, actively stimulate colonic motility through activation of Takeda G protein-coupled receptor 5. Third, the remarkable 60% reduction in overall complications can be mechanistically explained by bile’s antimicrobial properties and its essential role in maintaining intestinal barrier integrity.

Patient management following PTCD presents complex clinical challenges, particularly regarding postoperative gastrointestinal function optimization. Gastrointestinal dysfunction, encompassing delayed motility and increased discomfort, commonly complicates PTCD procedures and significantly impacts patient recovery[1]. Treatment of gastrointestinal motility disorders should initially trial oral nutrition, with jejunal or parenteral feeds serving to maintain or reinstate oral intake for reduced morbidity and mortality risk[12].

Early and effective nutritional support proves crucial for gastrointestinal recovery. The double-lumen jejunal nutrition tube facilitates bile reintroduction into the digestive tract, potentially restoring natural digestive processes disrupted by surgical interventions[13]. In selected patients failing gastrostomy feeding, jejunal tube feeding provides an alternative to parenteral nutrition[14]. Bile functions critically in fat emulsification and absorption of fat-soluble vitamins while maintaining intestinal flora stability. Bile reintroduction via double-lumen jejunal nutrition tubes may restore these essential functions, contributing to improved gastrointestinal motility and digestive health[8,9]. Enteral nutrition’s physiological stimulus maintains gastrointestinal barrier, immunological, and resorptive functions, with nutrients stimulating motility-regulating hormone secretion[15]. Traditional management involved “nil by mouth” protocols with sequential fluid and solid reintroduction after bowel function return. While some trials reported lower infectious complications and faster wound healing with early feeding, others showed no effect. Immediate energy intake could enhance recovery with fewer complications[16].

Study findings align with understanding that digestive process integrity proves crucial for recovery. Markedly shorter times to first flatus and defecation in the observation group suggest that bile reintroduction through double-lumen jejunal nutrition tubes positively influences gastrointestinal motility[6,10]. Enteral nutrition effects on gut microbiota and microbial markers predicting enteral nutrition intolerance will facilitate new nutrition intervention strategies[17,18].

Gastrointestinal function improvements prove particularly relevant given delayed motility’s impact on patient recovery and hospitalization duration. Reduced gastrointestinal symptoms including nausea, vomiting, abdominal pain, and bloating underscore this approach’s potential benefits in enhancing patient comfort. Exclusive enteral nutrition provides effective strategy with long-term feeding remodeling gut microbiota composition and alleviating intestinal mucosal inflammation[19,20].

Lower symptom frequency in the observation group suggests double-lumen jejunal nutrition tubes offer more comprehensive postoperative gastrointestinal management solutions, particularly relevant for patient quality of life and care satisfaction[21,22]. Dramatic nutrient provision changes to the intestine, along with metabolic stress and drug usage, cause marked dysbiosis characterized by dominant flora decrease and potentially pathogenic microorganism increase[23].

Observed improvements in bowel movement frequency, bowel sound duration, and gastrointestinal motility scores support the hypothesis that bile reintroduction through double-lumen jejunal nutrition tubes positively influences gastrointestinal function[24]. Fat-soluble vitamin malabsorption may occur despite adequate vitamin supply. Bile acids represent major cholesterol catabolism products playing crucial roles in fat and fat-soluble vitamin emulsification and absorption[25]. Results align with clinical understanding that natural digestive juice flow maintenance proves essential for normal gastrointestinal function[10,11]. Liver bile production provides constituents required for efficient intestinal fat absorption, with biliary cholesterol and phospholipid secretion proving important for body lipid homeostasis[8]. Bile acid synthesis involves glycine and taurine conjugation, promoting high intraluminal micellar concentrations facilitating lipid absorption. Genetic defects disrupting bile acid amidation cause fat-soluble vitamin deficiency, indicating bile acid conjugation's importance in lipid absorption[26].

The novel double-lumen jejunal nutrition tube offers promising methodology for enhancing gastrointestinal function recovery in PTCD patients. Findings suggest this approach may significantly improve various gastrointestinal recovery aspects, contributing to better overall patient outcomes[6,27]. Small intestinal micelles facilitate triglyceride and fat-soluble vitamin absorption[9]. Future research should explore this method’s long-term benefits and potential applications in other surgical contexts. Studies with larger sample sizes and extended follow-up periods are needed to fully understand this approach’s impact on patient recovery and quality of life[28].

Retrospective design introduces potential selection bias. Regarding potential temporal bias from the time-based patient allocation, we acknowledge this as an inherent limitation of the study design. However, several factors suggest that temporal confounding is unlikely to account for the observed effect sizes. Throughout the study period, perioperative care protocols remained standardized as detailed in the Methods section, with no systematic changes in surgical techniques, nursing protocols, or discharge criteria. The introduction of the double-lumen jejunal tube was the only intentional intervention change implemented as part of a quality improvement initiative. Small sample size (n = 60) limits power for rare complications. Single-center design may limit generalizability. Long-term outcomes beyond 30 days not assessed. Prospective randomized controlled trials with larger samples needed. Multi-center studies would enhance generalizability. Long-term follow-up should assess outcomes over months to years. Economic analyses including cost-effectiveness studies warranted. Investigation of optimal bile reinfusion protocols needed.

CONCLUSION

The self-made double-lumen jejunal nutrition tube significantly enhances outcomes in PTCD patients through improved nutritional status, faster gastrointestinal recovery, reduced complications, shorter hospital stays, and higher patient satisfaction. The approach is safe, practical, and economically feasible for diverse healthcare settings.