Biliary Drainage in Hilar and Perihilar Cholangiocarcinoma; 25-Year Experience at a Tertiary Cancer Center

Ahmad Al Nakshabandi; Faisal S Ali; Iyad Albustami; Hyunsoo Hwang; Wei Qiao; Nicole C Johnston; Abdullah S Shaikh; Emmanuel Coronel; Phillip S Ge; William Ross; Brian Weston; Jeffrey H Lee

doi:10.1016/j.gie.2023.12.006

Biliary Drainage in Hilar and Perihilar Cholangiocarcinoma; 25-Year Experience at a Tertiary Cancer Center

Gastrointest Endosc. 2023 Dec 11:S0016-5107(23)03150-4. doi: 10.1016/j.gie.2023.12.006. Online ahead of print.

Affiliations

¹ Gastroenterology, Hepatology, and Nutrition Department, The University of Texas MD Anderson Cancer Center.
² Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center.
³ Gastroenterology, Hepatology, and Nutrition Department, The University of Texas MD Anderson Cancer Center. Electronic address: jefflee@mdanderson.org.

PMID: 38092128
DOI: 10.1016/j.gie.2023.12.006

Abstract

Introduction: This study analyzes the optimal biliary stenting strategy for palliation in cholangiocarcinoma (CCA).

Methods: This is a retrospective study of patients with CCA who underwent biliary drainage from 1997-2023. A per-patient analysis of percutaneous biliary drainage (PTBD) rates, the median number of ERCPs, overall survival (OS), and a per-procedure analysis of clinical success (CS), stent-specific Adverse Events (AEs), and mean time to reintervention by stent type and laterality (unilateral(u) & bilateral(b)) is presented.

Results: A total of 333 patients underwent 1,050 ERCPs; 85% with plastic stents (PS). PTBD was eventually done in 23% of PS patients, 35% of whom had PS removed prior to PTBD. ERCPs with SEMS/uniSEMS use had higher CS (89%/91%) vs PS/uPS (85% both) and PS within SEMS (PS-SEMS)/uPS-SEMS (71%/74%;p=0.013/p=0.054). Compared to PS, SEMS and PS-SEMS were associated with higher stent-specific AEs (OR SEMS 4.85; 3.23-7.27; PS-SEMS 9.99; 5.33-18.71;p<0.001). Straight PS were associated with more stent-specific AEs compared to double-pigtail stents (OR 6.74; 3.95-11.45;p<0.001). More 7 Fr stents were used in cases with balloon dilation (BD, 109 vs. 88 with no BD; p<0.001). BD had 79% CS rate vs 87% without BD (p<0.001). Cases with pus on ERCP and those with BD had a shorter mean time to reintervention. On regression analyses, higher Bismuth class, PS use, and PS-SEMS use were associated with a shorter mean time to repeat ERCP. 52% of patients in the bSEMS arm died from cholangitis (p=0.005).

Conclusion: The relatively higher clinical success of SEMS is countered by the higher stent-specific complication rate. PS can be removed and may better facilitate PTBD. Within PS types, DPTs may have fewer stent-specific AEs. Cases requiring balloon dilation and with endoscopic evidence of pus may benefit from earlier reintervention.