Performance of Initial Biliary Drainage in Patients with Unresectable Perihilar Cholangiocarcinoma

Introduction: Patients with unresectable perihilar cholangiocarcinoma (pCCA) require biliary drainage to relieve symptoms and allow for palliative systemic chemotherapy. The aim of this study was to establish the success, complication, and mortality rates of the initial biliary drainage procedure in patients with unresectable pCCA. Method: Patients with unresectable pCCA who underwent endoscopic (EBD) or percutaneous transhepatic biliary drainage (PTBD) between 2002 and 2014 were included. Success of drainage was defined as successful biliary stent or drain placement, without unscheduled reintervention within 14 days. Serum bilirubin levels below 50 μmol/L or a more than 50% decrease in serum bilirubin after 14 days were recorded, as were severe complications and mortality within 90 days. Results: In total, 186 patients were included; 161 (87%) underwent initial EBD and 25 (13%) initial PTBD. Success of initial drainage was observed in 79 patients (43%), including 73 (45%) after EBD and 6 (24%) after PTBD (figure). Reasons for unsuccessful initial drainage were: no drain or stent placed in 39 patients (21%), unplanned reintervention in 52 patients (28%), and bilirubin level above 50 μmol/L (or not halved) in 16 patients (9%). Severe drainage-related complications were observed in 19 patients (12%) after EBD and in 3 (12%) after PTBD. Sixty-six patients (36%) died within 90 days after initial biliary drainage. Risk factors are listed in the appended table. Conclusions: In this cohort we observed that initial biliary drainage in patients with unresectable pCCA has a low success rate of 45% and a high 90-day mortality rate of 36%. Tabled 1EP03A-035Table. 90 day logistic regression analysisUnivariable OR (95% CI)p valueMultivariable OR (95% CI)p valueAge ≥75 years1.11 (0.60-2.06)0.731Sex (male)1.58 (0.86-2.93)0.1441.55 (0.77-3.14)0.218Cholangitis prior to drainage procedure1.18 (0.37-3.79)0.779Tumor size >3cm1.59 (0.84-3.03)0.1561.04 (0.94-1.16)0.444Bismuth III or IV0.51 (0.24-1.12)0.0880.50 (0.22-1.13)0.097Approach of initial biliary drainageEBDRefPTBD1.25 (0.53-2.96)0.612Success of initial drainage0.93 (0.51-1.70)0.804 Open table in a new tab