Biliary drainage of hilary malignant biliary stenosis: evaluation of the risk of pancreatitis, survival, morbidity according to the type and quality of drainage

Aims ESGE guidelines recommend to drain more than 50% of the liver in case of palliative drainage of malignant biliary hilary stenosis (DMBHS). Asian guidelines discuss to drain until 80% of the liver [1]. The type of drainage is discussed (percutaneous path, EUS drainage or ERCP), regarding klastkin classification of the hilary stenosis. Morbidity could be high around 40% with high rate of pancreatitis. Main Goal of the study was to evaluate the rate of pancreatitis according to the number of trans-papillary stent. Socondary objectives were survival according to the percentage of liver drained et evaluation of the different technique of drainage used.

Methods All patients with DMBHS were included from January 2015 to August 2022 in our center. Pancreatis was defined as association of pain and high lipasemia and/or imaging with a diagnosis of pancreatitis.Percentage of liver drained was defined by the number of liver segment drained/number of functional liver segments [2]. Morbidity was the rate of complication within the month post biliary drainage with AGREE classification. Re-Endoscopy before 7 days was not considered as an endoscopy for complication but was included in the same first management of the hilary stenosis.

Results 312 patients 170-54%- men), mean age of 69.5 years were included. Histology of the stenosis was cholangiocarcinoma in 39% (121) of the cases, a metastasis in 57% (179), another primitive tumor in 4% (12) of the patients. Klatskin classification was type I for 11.7% (29), II for 29.4% (73), III for 25% (62), IV for 33.9% (84) patients. 199 patients were drained only by ERCP. The others could be drained wit EUS-guided technique, percutaneous path, a combinaison of 2 or 3 techniques respectively for 4.2% (13), 5.2% (16), 23% (73), and 2.9% (9) patients. Global survival was 121.8 days. 42% of the patients could benefit of chemotherapy post biliary drainage. Morbidity grade III and IV was 12%. Specific mortality was 1.6%. Mean hospitalization was 9.5 days. The rate of pancreatitis increases significantly (p<0.05) with the number of trans-papillary stents avec rates of 5.3%, 6.9%, 18.4%, 20% for 1, 2, 3, and 4 trans-papillary stents. Survival was better in group of patients with a drainage>75% of the functional liver drained (p<0.001) whatever the technique of drainage used. Global morbidité (Agree 1 to 4) was lower in the group of patients drained only by EUS (18.8%), followed by the group drained by EUS and ERCP (28%).

Conclusions Pancreatitis rate increase with the number of trans papillary stents placed. A drainage of more than 75% of the functional liver is associated with better survival. Drainage with EUS seems to be associated with less morbidity. A association ERCP with EUS may be performed more frequently in order to decrease morbidity with a focus on pancreatitis.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Caillol F, Bories E, Zemmour C. et al. Palliative endoscopic drainage of malignant stenosis of biliary confluence: Efficiency of multiple drainage approach to drain a maximum of liver segments. United Eur Gastroenterol J 2019; 7 (01): 52-9
• 2 Angsuwatcharakon P, Kulpatcharapong S, Chuncharunee A. et al. The updated Asia-Pacific consensus statement on the role of endoscopic management in malignant hilar biliary obstruction. Endosc Int Open 2024; 12: E1065-E1074