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Endoscopic biliary drainage improves outcomes for pancreatic cancer, cholangiocarcinoma
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Endoscopic biliary draining yielded a superior adverse event rate compared with percutaneous drainage among patients with pancreatic cancer, according to the results of a retrospective cohort study.
Further, the procedure appeared associated with superior outcomes among patients with cholangiocarcinoma treated at centers with a low volume of percutaneous biliary draining procedures.
Thus, endoscopic biliary draining should be considered a preferred first-line intervention for malignant biliary obstruction, according to the researchers.
"Biliary drainage is the cornerstone of treatment of various malignant biliary disorders, such as pancreatic cancer and cholangiocarcinoma,” Arvind J. Trindade, MD, assistant professor of medicine in the division of gastroenterology, hepatology and nutrition at North Shore-Long Island Jewish Medical Center in New Hyde Park, New York, and colleagues wrote. “Biliary drainage allows for symptom relief of jaundice and pruritus, for normalization of liver function tests, and, in addition, allows for a diagnosis by biopsy or cytology brushing.”
Nonsurgical biliary drainage can be performed endoscopically by endoscopic retrograde cholangiopancreatography (ERCP) or by percutaneous transhepatic biliary drainage (PTBD). However, little has been written to support either approach and studies have offered conflicting results, according to study background.
Trindade and colleagues sought to evaluate the procedure-related adverse event rate of endoscopic vs. percutaneous drainage in patients with malignant biliary tract obstruction.
The researchers conducted a retrospective analysis by accessing the National Inpatient Sample database from 2007 through 2009. The database included cases from academic and community medical centers.
Adverse event rate served as the primary endpoint.
The study included data from 9,135 patients, 81.5% (n = 7,445) of whom underwent ERCP. The other 18.5% (n = 1,690) underwent PTBD.
The overall adverse event rate was 8.6% (640 events) for endoscopic drainage, compared with 12.3% (208 events) for percutaneous drainage (P < .001).
When analyzed by type of malignant neoplasm, ERCP appeared associated with a lower rate of adverse events compared with PTBD for pancreatic cancer (2.9% vs. 6.2%; OR = 0.46; 95% CI, 0.35-0.61) and cholangiocarcinoma (2.6% vs. 4.2%; OR = 0.62; 95% CI, 0.35-1.1).
Among patients with pancreatic cancer, endoscopic procedures yielded a lower rate of adverse events regardless of the volume of percutaneous procedures performed by a center. However, for patients with cholangiocarcinoma, centers that performed a low volume of percutaneous biliary drainage procedures were more likely to have adverse events compared with endoscopic procedures performed at the same center (5.7% vs. 2.5%; OR = 2.28; 95% CI, 1.02-5.11).
ERCP and PTBD adverse event rates were similar at centers that performed a high number of percutaneous drainage procedures (3.5% vs. 3%; OR = 1.18; 95% CI, 0.53-2.66).
The researchers identified limitations of their study. Due to the retrospective design, they could not determine why patients chose to undergo a specific procedure. Further, relevant data such as local expertise for one method over another or patient-specific clinical factors could not be captured.
“Despite its limitations, we believe our study adds considerably to the limited published literature,” Trindade and colleagues wrote. “Our study shows that patients who undergo ERCP for biliary drainage in malignant biliary obstruction have lower procedure-related adverse event rates compared with those who undergo PTBD in pancreatic cancer in all centers and cholangiocarcinoma in low-volume centers. … Larger prospective randomized controlled trials are still needed to expand on our experience and to address specific clinical scenarios.” – by Cameron Kelsall
Disclosure: One researcher reports a consultant role with Boston Scientific. The other researchers report no relevant financial disclosures.
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