Efficacy and safety analysis of continued nursing of complications in discharged patients after percutaneous transhepatic biliary drainage

Abstract

BACKGROUND

Percutaneous hepatobiliary drainage (PTCD) is an effective method for the treatment of biliary obstruction and other diseases, but postoperative complications are still one of the important problems faced by patients. Continuous nursing is a comprehensive nursing model that plays an important role in postoperative recovery. The purpose of this study was to investigate the effect of continuous nursing on the incidence of complications in patients after PTCD surgery through meta-analysis and to evaluate its efficacy and safety.

AIM

To evaluate the effect of extended nursing on the incidence of complications in discharged patients after percutaneous transhepatic biliary drainage (PTBD).

METHODS

Randomized controlled studies on PTBD postdischarge extended care were identified in the CNKI, Wanfang, VIP, CBM, PubMed, Cochrane Library, Embase, Web of Science, and other databases. The quality of the included studies was evaluated using the Joanna Briggs Institute of Australia literature quality evaluation tool, and a meta-analysis of the included studies was performed with RevMan 5.4 software.

RESULTS

Finally, 9 studies were included, with a total sample size of 854 patients (425 patients in the control group and 429 patients in the intervention group). Meta-analysis revealed that extended care effectively reduced biliary tract infection (RR: 0.42, 95%CI: 0.30-0.57), puncture wound infection (RR: 0.19, 95%CI: 0.06-0.65), catheter protrusion or displacement in discharged patients after PTBD (RR: 0.31, 95%CI: 0.18-0.54), catheter blockage (RR: 0.23, 95%CI: 0.13-0.42), skin infection around the drainage tube (RR: 0.30, 95%CI: 0.12-0.77), and catheter-related readmissions (RR: 0.34, 95%CI: 0.18-0.65) (P < 0.05).

CONCLUSION

Compared with conventional discharge care, extended care can effectively reduce the occurrence of complications such as biliary tract infection, puncture wound infection, catheter prolapse or displacement, catheter blockage, skin infection around the drainage tube, and catheter-related readmission in discharged patients after PTBD.

Key Words: Extended care, Percutaneous transhepatic puncture biliary drainage, Complications, Continued nursing, Meta-analysis

Core Tip: To evaluate the effect of continuous care on the incidence of complications in discharged patients after percutaneous hepatobiliary drainage through meta-analysis and to explore its efficacy and safety. We will systematically collect relevant literature and comprehensively analyze the role of continuous care in reducing postoperative complications and promoting patients' recovery. This study is of great significance for guiding clinical practice and is expected to provide a more effective nursing mode for medical staff and reduce the risk of postoperative complications for patients.

INTRODUCTION

The incidence of malignant obstructive jaundice is high, and percutaneous transhepatic biliary drainage (PTBD) has become the main palliative therapy with good curative effects, little trauma, and quick recovery[1]. However, most patients need to survive with a tube for a long time after surgery, and many problems may occur, such as biliary tract infection, catheter blockage or shedding, fluid seepage at the puncture site, and bile duct bleeding, which seriously affect the quality of life and prognosis of patients. Studies[2,3] have shown that PTBD postoperative nursing problems mainly occur outside the hospital, and good discharge nursing management is very important for reducing the occurrence of tubular complications. Extended care generally refers to the transitional care that patients receive when they return to their families or society after discharge. It helps patients continue to receive effective medical services through multichannel and multiform out-of-hospital nursing services and health guidance. It is an extension and expansion of in-hospital care, aiming to reduce the occurrence of related complications, reduce the rate of unplanned readmissions, and promote rehabilitation. There are many studies[4,5] on the effectiveness of multimode continuous nursing after PTBD for reducing complications, but the results are inconsistent, and there is a lack of systematic multicenter evaluations. In this study, a meta-analysis was used to quantitatively evaluate the effect of extended care on reducing complications in discharged patients after PTBD, providing evidence-based evidence for high-quality extended care.

MATERIALS AND METHODS

Literature retrieval strategy

The PTBD data were retrieved from the CNKI, Wanfang, VIP, CBM, PubMed, Cochrane Library, Embase, and Web of Science databases in October 2023. This was a Chinese and English randomized controlled study of postdischarge extended care. The search term combines the main title with the free word. Keywords: extended care, continuous care, home care, discharge care, percutaneous transhepatic biliary drainage, malignant obstructive jaundice, biliary drainage, application, impact, complications, quality of life.

Criteria for inclusion and exclusion of references

The inclusion criteria were as follows: (1) Patients who were discharged after PTBD; (2) The control group received routine discharge nursing, the intervention group received extended nursing or continued nursing on the basis of routine nursing, and the general data of the two groups were not significantly different; (3) The evaluation indices were biliary tract infection, drainage tube displacement, drainage tube blockage, puncture wound infection, and skin infection around the drainage tube after PTBD; and (4) The study type was a randomized controlled trial. The exclusion criteria were as follows: (1) Duplicate studies; (2) The literature content was incomplete, and the data could not be extracted; and (3) Literature review, case report, experience summary, meta-analysis, guidelines, consensus, etc.

Literature screening, data extraction, and quality assessment

Two researchers with the ability to conduct evidence-based research independently screened the literature, and a third researcher was invited to negotiate and judge any disagreements. Endnote X9 software was used to remove duplicate literature; the titles and abstracts were read to remove inconsistent literature; and literature with unreasonable experimental design, data extraction, and poor quality was removed after further reading the full text. Finally, the literature was included in this study. The methodological quality of the included studies was evaluated using the Joanna Briggs Institute of Australia (JBI) literature quality evaluation tool. The JBI evaluation tool contains 13 items, which can be used to determine whether the literature is truly randomized and assigned to hide, whether the baseline of each study group is comparable, whether the study object, intervention implementers, and outcome evaluators are blinded, and whether measures other than validated intervention measures are the same to determine whether the study is included. The risk of literature bias was assessed using RevMan 5.4 software.

Statistical methods

The meta-analysis was performed using RevMan 5.4 software. Relative risk (RR) and 95%CI were used as statistics for bicategorical variables, and I² was used to test the heterogeneity between studies. P ≥ 0.05 and I² ≤ 50% were considered to indicate homogeneity in the included studies. A fixed-effects model was used for the meta-analysis. P < 0.05 and I² > 50% indicated significant heterogeneity in the included studies. Sensitivity analysis was used to remove literature with significant weights and recalculate the overall association results. When heterogeneity could not be eliminated, a random effects model was selected for analysis. The funnel plot of the meta-analysis and the Egger test of Stata software were used to determine whether there was publication bias.

RESULTS

Literature screening

A total of 736 studies were retrieved (28 CNKI articles, 206 Wanfang articles, 19 VIP articles, 26 CBM articles, 5 PubMed articles, 239 Embase articles, 21 Cochrane Library articles, and 192 Web of Science articles). After review, 51 duplicate references were removed, 607 were removed after the titles and abstracts were read, and 69 were removed after the full texts were read. Finally, 9 valid references were included[6-14] (Figure 1).

Figure 1 Flow chart of literature retrieval and screening.

Basic features of the included literature

The nine included studies[6-14] with a total sample size of 854 patients (425 patients in the control group and 429 patients in the intervention group) were randomized controlled trials in China. Literature data were extracted and tabulated, including the study authors, sample size, intervention measures, and complication outcome indicators. The basic characteristics of the included studies are shown in Table 1.

Table 1 Basic characteristics of included literature.

Ref.	Intervention group/control group (n)	Post discharge intervention measures		Outcome indicators for complications
		Control group	Intervention group
Yan et al[6], 2012	51/48	Regular health	Regular health guidance + telephone intervention	4, 6, 7
Mai et al[7], 2015	30/30	Telephone follow-up	Continuing care intervention	1, 6, 7, 9
Yu et al[8], 2016	30/30	Regular health education	Regular health education + continuing care	1, 5
Ou et al[9], 2017	50/50	Telephone follow-up	Continuous care model on mobile platforms	1, 6, 7, 4
Ji et al[10], 2018	54/54	Usual care	Nurse led "hospital community family" linkage	1, 2, 3, 4
Chen et al[11], 2019	50/50	Usual care	Extended care	1, 2, 3, 4
Huang et al[12], 2019	50/50	Regular health education	QR code management	1, 6, 7, 10
Wang et al[13], 2021	75/75	Regular health education	Regular health education + WeChat group	1, 6, 7, 4
Li et al[14], 2022	39/38	Usual care	Routine care + continuity of case management	1, 3, 6, 7

Evaluation of the quality of the JBI literature methodology

The evaluation results of the JBI quality evaluation tool on the methodological quality of the included documents are shown in Table 2. According to the findings of the RevMan 5.4 software bias risk assessment of the included literature, the relevant studies used a group design as their experimental method, and the random sequence that resulted from the assessment had a high risk rating (Figure 2).

Figure 2 Risk analysis of literature bias.

Table 2 Methodological quality results of the JBI quality evaluation tool included in the literature evaluation.

Ref.	Randomization	Analysis of results of randomized study subjects by inclusion group	Same evaluation method	The evaluation method is reliable	Appropriate statistical methods	Reasonable experimental design
Yan et al[6], 2012	Yes	Yes	Yes	Yes	Yes	Yes
Mai et al[7], 2015	Yes	Yes	Yes	Yes	Yes	Yes
Yu et al[8], 2016	Yes	Yes	Yes	Yes	Yes	Yes
Ou et al[9], 2017	Yes	Yes	Yes	Yes	Yes	Yes
Ji et al[10], 2018	Yes	Yes	Yes	Yes	Yes	Yes
Chen et al[11], 2019	Yes	Yes	Yes	Yes	Yes	Yes
Huang et al[12], 2019	Yes	Yes	Yes	Yes	Yes	Yes
Wang et al[13], 2021	Yes	Yes	Yes	Yes	Yes	Yes
Li et al[14], 2022	Yes	Yes	Yes	Yes	Yes	Yes

Results of the meta-analysis

Eight articles[7-14] mentioned the effect of extended care on the incidence of biliary tract infection after PTBD, with a total of 755 patients (378 in the intervention group and 377 in the control group). Heterogeneity among studies was low (P = 0.75, I² = 0%). A fixed-effects model showed that extended care could effectively reduce the incidence of biliary tract infection after PTBD compared with conventional discharge care (RR = 0.42, 95%CI: 0.30-0.57, P < 0.01), as shown in Figure 3A.

Figure 3 Meta-analysis results. A: Effect of extended nursing on the incidence of biliary tract infection after percutaneous transhepatic biliary drainage (PTBD); B: Effect of extended nursing on the incidence of puncture wound infection after PTBD; C: Effect of extended care on the incidence of catheter prolapse or displacement after PTBD; D: Effect of extended care on the incidence of catheter blockage after PTBD; E: Effect of extended care on the incidence of skin infection around drainage tubes after PTBD; F: Effect of extended care on catheter-related readmissions after PTBD.

Three studies[10-11,14] mentioned the effect of extended nursing on the incidence of wound infection at the puncture site after PTBD, involving a total of 285 patients (143 in the intervention group and 142 in the control group). Heterogeneity among studies was low (P = 0.84, I² = 0%). A fixed-effects model showed that compared with conventional discharge care, extended care could effectively reduce the incidence of puncture wound infection after PTBD (RR: 0.19, 95%CI: 0.06-0.65, P = 0.008), as shown in Figure 3B.

Seven articles[6-9,12-14] involving 569 patients (286 in the intervention group and 283 in the control group) mentioned the effect of extended care on the incidence of catheter prolapse or displacement after PTBD. Heterogeneity among studies was low (P = 0.99, I² = 0%). A fixed-effects model showed that compared with conventional discharge care, extended care could effectively reduce the incidence of catheter detachment or displacement after PTBD (RR: 0.31; 95%CI: 0.18–0.54; P < 0.01), as shown in Figure 3C.

Seven articles[6-9,12-14] mentioned the effect of extended care on the incidence of catheter blockage after PTBD, involving a total of 646 patients (325 in the intervention group and 321 in the control group). Heterogeneity among studies was low (P = 0.94, I² = 0%). A fixed-effects model showed that extended care could effectively reduce the incidence of catheter blockage after PTBD compared with conventional discharge care (RR: 0.23, 95%CI: 0.13-0.42, P < 0.01), as shown in Figure 3D.

Three studies[7,9,13] mentioned the effect of extended care on the incidence of skin infection around drainage tubes after PTBD, with a total of 310 patients (155 in the intervention group and 155 in the control group). Heterogeneity among studies was low (P = 0.49, I² = 0%). A fixed-effects model showed that, compared with conventional discharge care, extended care could significantly reduce the incidence of skin infection around drainage tubes after PTBD (RR: 0.30, 95%CI: 0.12-0.77, P < 0.01), as shown in Figure 3E.

Three studies[6,10-11] involving a total of 307 patients (155 in the intervention group and 152 in the control group) reported the effect of extended care on catheter-related readmission rates after PTBD. Heterogeneity among studies was low (P = 0.68, I² = 0%). Fixed-effect model tests showed that extended care was more effective than conventional discharge care in reducing catheter-related readmission rates after PTBD (RR: 0.34, 95%CI: 0.18–0.65, P < 0.001), as shown in Figure 3F.

The results of publication bias detection showed that all funnel plots in the meta-analysis were evenly distributed and basically symmetrical, and Egger’s test indicated that there was basically no publication bias in the included studies (P = 0.141). The funnel diagram of publication bias is shown in Figure 4.

Figure 4 Biased funnel plot analysis. A: Biliary tract infection; B: Puncture wound infection; C: Readmission for catheter-related reasons; D: Catheter prolapse/displacement; E: Catheter blockage; F: Skin infection around the drainage tube.

DISCUSSION

PTBD, as the main palliative therapy, is effective in the treatment of malignant obstructive jaundice, but most patients need long-term surgical tube placement, which may cause many complications[15-17]. In this study, a meta-analysis was performed to quantitatively evaluate the effect of extended nursing on reducing complications after PTBD. The results showed that the incidence of common complications after discharge (biliary tract infection, puncture wound infection, catheter ejection or displacement, catheter blockage, skin infection around the drainage tube, and catheter-related readmission) in the intervention group receiving extended care was significantly lower than that in the control group receiving conventional care.

There are many complications and difficulties in nursing after PTBD, which may be due to the following reasons: (1) Long-term survival of patients who undergo catheterization is often accompanied by old age, malnutrition, coagulation dysfunction, a previous history of bile duct surgery, and biliary liver damage, which greatly increases the risk of postoperative biliaemia and easily leads to biliary tract infection; (2) due to the low resistance of patients, combined with improper self-care, wound seepage, no timely change in wound dressing, etc., easily leads to puncture wound infection; (3) lack of knowledge of tube survival and tube maintenance, coupled with physical activity disorders, old age, and inadequacy, can easily lead to catheter prolapse or displacement; (4) improper pipeline maintenance, combined with biliary tract infection, catheter displacement, not timely follow-up, etc., makes drainage tube blockage easy; (5) medical viscose-related skin injuries, pressure damage to pipes and fixed materials, seepage, allergies, etc., are the main causes of skin infection around the drainage tube; and (6) Biliary tract infection, puncture wound infection, catheter ejection or displacement, catheter blockage, and skin infection around the drainage tube greatly increase the incidence of unplanned readmission[18-20]. Various complications after PTBD seriously affect the comfort, compliance, and quality of life of patients, and the treatment effect is difficult to guarantee. These complications mainly occur after discharge, so it is particularly important to do a good job of extended care[21-23]. This meta-analysis showed that continuous care built a patient-patient, doctor-patient, and nurse-patient home care platform through multichannel and multiform personalized plans such as telephone guidance, WeChat push, home visits, hospital-community-family linkage, and procedures such as evaluation, planning, implementation, and evaluation, which were helpful for effectively guiding and training patients to carry out routine pipeline maintenance[24]. To achieve the purpose of mastering the observation of drainage fluid, drainage bags must be replaced, and complications must be identified[25-28]. Detailed explanations and supervision of disease knowledge, diet and nutrition, daily rest and activities, medication, etc., and regular health promotion can effectively improve patients' negative mood, build self-confidence and a sense of hope, and establish confidence in overcoming the disease[29-32]. At the same time, patients' information is accepted at any time, timely answers to questions are provided, and help is provided so that patients can continue to receive health care[33-35]. The incorrect nursing mode should be corrected in a timely manner, and risk factors should be controlled to effectively reduce the occurrence of tubular complications.

Extended nursing started late in China, and there are many problems, such as the relatively single method, the uneven professional level of personnel involved in extended nursing intervention, subjectivity and instability in the service process, and the many problems of patient discharge nursing and inability to achieve standardized and homogenized nursing intervention[36]. The implementers of extended care are often senior practice nurses in foreign countries and mainly hospital nurses in China. Some patients trust and expect the guidance of competent doctors more when accepting extended care interventions[37-39]. Therefore, it is necessary to create and develop multiform continuation care models according to the different needs of patients, train and promote higher-level professional intervention personnel, improve the quality of continuation care, and promote the rehabilitation of patients.

CONCLUSION

In conclusion, continuing nursing has a positive effect on reducing the occurrence of complications in discharged patients after PTBD. This study also has several limitations. For example, only the published literature in the database was retrieved, the overall quality of the included literature was general, the specific intervention methods, intervention duration, and intervention frequency were different in most studies, the sample size of some studies was small, and the blinding method was not implemented in the evaluation of the research results, all of which may affect the credibility of the evidence. In the future, large-scale, high-quality randomized controlled studies should be conducted to further validate the findings.