Percutaneous transhepatic biliary drainage may be the preferred preoperative drainage method in hilar cholangiocarcinoma

Abstract

Background and study aims Preoperative biliary drainage of hilar cholangiocarcinoma (HC) is controversial. The goal of this study was to compare the clinical outcome and associated complications for types II, III, and IV HC managed by percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP).

Patients and methods Between January 2011 and June 2017, a total of 180 patients with II, III, and IV HC were enrolled in this retrospective cohort study. According to the drainage method, patients were divided into two groups: PTBD (n = 81) and ERCP (n = 99). This study was registered with ClinicalTrials.gov, NCT03104582, and was completed.

Results Compared with the PTBD group, the ERCP group had a higher incidence of post-procedural cholangitis (37 [37.37 %] vs. 18 [22.22 %], P = 0.028) and pancreatitis (17 [17.17 %] vs. 2 [2.47 %], P = 0.001); required more salvaged biliary drainage (18 [18.18 %] vs. 5 [6.17 %], P  = 0.029), and incurred a higher cost (P < 0.05). Patients with type III and IV HC in the ERCP group had more cholangitis than those in the PTBD group (26 [36.62 %] vs. 11 [18.03 %], P = 0.018). The rate of cholangitis in patients who received endoscopic bilateral biliary stents insertion was higher than patients with unilateral stenting (23 [50.00 %] vs. 9 [26.47 %], P = 0.034), and underwent PTBD internal-external drainage had a higher incidence of cholangitis than those with only external drainage (11 [34.36 %] vs. 7 [14.29 %], P = 0.034). No significant difference in the rate of cholangitis was observed between the endoscopic unilateral stenting group and the endoscopic nasobiliary drainage group (9 [26.47 %] vs. 5 [26.32 %], P = 0.990).

Conclusion Compared to ERCP, PTBD reduced the rate of cholangitis, pancreatitis, salvage biliary drainage, and decreased hospitalization costs in patients with types II, III, and IV HC. Risk of cholangitis for patients with types III and IV was significantly lower in the PTBD group.

^* Yongjiang Ba and Ping Yue make the same contribution to this work.

• References

• 1 Polistina FA, Guglielmi R, Baiocchi C. et al. Chemoradiation treatment with gemcitabine plus stereotactic body radiotherapy for unresectable, non-metastatic, locally advanced hilar cholangiocarcinoma. Results of a five year experience. Radiother Oncol 2011; 99: 120-123
• 2 Paik WH, Park YS, Hwang JH. et al. Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc 2009; 69: 55-62
• 3 Byrnes V, Afdhal N. Cholangiocarcinoma of the hepatic hilum (Klatskin tumor). Curr Treat Options Gastroenterol 2002; 5: 87-94
• 4 Castellano-Megías VM, Andrés ID, Colina-Ruizdelgado F. Pathological aspects of so called “hilar cholangiocarcinoma”. World J Gastrointest Oncol 2013; 5: 159-170
• 5 Ramos E. Principles of surgical resection in hilar cholangiocarcinoma. World J Gastrointest Oncol 2013; 5: 139-146
• 6 Govil S, Reddy MS, Rela M. Surgical resection techniques for locally advanced hilar cholangiocarcinoma. Langenbeck Arch Surg 2014; 399: 707-716
• 7 Rd VV, Cosgrove D, Herman JM. et al. Management of perihilar cholangiocarcinoma in the era of multimodal therapy. Expert Rev Gastroent 2012; 6: 481-495
• 8 Soares KC, Kamel I, Cosgrove DP. et al. Hilar cholangiocarcinoma: diagnosis, treatment options, and management. Hepatobil Surg Nutr 2014; 3: 18-34
• 9 Spiegel B, Bolus R, Harris LA. et al. Measuring irritable bowel syndrome patient-reported outcomes with an abdominal pain numeric rating scale. Aliment pharm therap 2009; 30: 1159-1170
• 10 Kiriyama S, Takada T, Strasberg SM. et al. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2013; 20: 24-34
• 11 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
• 12 Cotton PB, Garrow DA, Gallagher J. et al. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009; 70: 80-88
• 13 Parikh K, Ali MA, Wong RC. Unusual causes of upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am 2015; 25: 583-605
• 14 Aljiffry M, Abdulelah A, Walsh M. Evidence-based approach to cholangiocarcinoma: a systematic review of the current literature. J Am Coll Surg 2009; 208: 134-147
• 15 Farges O, Regimbeau JM, Fuks D. et al. Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma. Br J Surgery 2013; 100: 274-283
• 16 Lafemina J, Jarnagin WR. Surgical management of proximal bile duct cancers. Langenbeck Arch Surg 2012; 397: 869-879
• 17 Sakata J, Shirai Y, Tsuchiya Y. et al. Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma. Langenbeck Arch Surg 2009; 394: 1065-1072
• 18 Ribero D, Zimmitti G, Aloia TA. et al. Preoperative cholangitis and future liver remnant volume determine the risk of liver failure in patients undergoing resection for hilar cholangiocarcinoma. J Am Coll Surg 2016; 223: 87-97
• 19 Kloek JJ, Na VDG, Aziz Y. et al. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg 2010; 14: 119-125
• 20 Miyazaki M, Yoshitomi H, Miyakawa S. et al. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition. J Hepatobiliary Pancreat Sci 2015; 22: 249-273
• 21 Rerknimitr R, Angsuwatcharakon P, Ratanachu-Ek T. et al. Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol 2013; 28: 593-607
• 22 Vienne A, Hobeika E, Gouya H. et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc 2010; 72: 728-735
• 23 Yasuda I, Mukai T, Moriwaki H. Unilateral versus bilateral endoscopic biliary stenting for malignant hilar biliary strictures. Digest Endosc 2013; 25: 81-85
• 24 Tang Z, Yang Y, Meng W. et al. Best option for preoperative biliary drainage in Klatskin tumor: A systematic review and meta-analysis. Medicine 2017; 96: e8372
• 25 Min KK, Won PJ, Kyun LJ. et al. A comparison of preoperative biliary drainage methods for perihilar cholangiocarcinoma: endoscopic versus percutaneous transhepatic biliary drainage. Gut Liver 2015; 9: 791-799
• 26 De Palma GD, Galloro G, Siciliano S. et al. Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study. Gastrointest Endosc 2001; 53: 547-553
• 27 Iwano H, Ryozawa S, Ishigaki N. et al. Unilateral versus bilateral drainage using self-expandable metallic stent for unresectable hilar biliary obstruction. Digest Endosc 2011; 23: 43-48
• 28 Kawakami H, Kuwatani M, Onodera M. et al. Endoscopic nasobiliary drainage is the most suitable preoperative biliary drainage method in the management of patients with hilar cholangiocarcinoma. J Gastroenterol 2011; 46: 242-248
• 29 Xu C, Huang XE, Wang SX. et al. Comparison of infection between internal-external and external percutaneous transhepatic biliary drainage in treating patients with malignant obstructive jaundice. Asian Pac J Cancer Prev 2015; 16: 2543-2546