Palliative endoscopic drainage of malignant stenosis of biliary confluence: Efficiency of multiple drainage approach to drain a maximum of liver segments

Abstract

Background and aim: More than 50% of the liver should be drained in case of unresectable hilar liver stenosis; however, it remains unclear if the use of several types of drainage (endoscopic retrograde cholangiography and pancreatography, percutaneous-biliary drainage, endoscopic ultrasound biliary drainage (EUS-BD)), allowing better drainage, has an impact on survival. The aim of our study was to evaluate the percentage of liver drained and its correlation on survival whatever the drainage technique used.Patients and methods: This study was a retrospective analysis of a prospective registry of patients with malignant drainage stenosis of the hilum. The quality of drainage was evaluated based on the percentage of liver segments drained, which was calculated by dividing the number of liver segments drained by the total number of liver segments. Drainage could be achieved via an endoscopic, EUS-guided or percutaneous route not associated with the procedure. Results: Sixty patients (38 men) were included from January 2015 to July 2016. The mean patient age was 69.84 years. Stenosis was classified as type II for 17 (29%) patients, type III for 20 (34%) patients, and type IV for 22 (37%) patients. Histology revealed cholangiocarcinoma for 26 (43%) patients, metastatic disease from colorectal cancer for 15 (25%) patients and another cancer for 19 (32%) patients. The median survival time was five (2.3-12.3) months. The percentage of liver segments drained had a significant prognostic impact on overall survival regardless of the technique used to drain the liver. The percentage of liver segments drained was dichotomized based on a threshold value of 80%, resulting in two groups (<80% and !80%). Univariate analysis of overall survival revealed that the patients with <80% of liver segments drained had significantly worse prognoses (hazard ratio (HR) ¼ 3.25 (1.66-6.36), p < 0.001) than the patients with !80% of liver segments drained. This effect was confirmed in multivariate analysis , p ¼ 0.02). The other factor that affected survival was invasion of <50% of the liver by the tumor. A receiver operating characteristic curve was used to establish a correlation between patients receiving chemotherapy and the percentage of liver drained (area under the curve ¼ 0.77 (0.65-0.88)). Conclusion: The survival of patients with malignant stenosis of the biliary confluence is highly correlated with the percentage of liver segments drained, regardless of the technique used.Keywords ERCP, hilar stenosis, palliative biliary drainage, biliary hilum stenting, EUS-guided biliary drainage of the liver hilum

The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma

“…The drainage area was determined based on the findings from MDCT. 15,16 Initial drainage: For the PS group, after 0.025 GWs were placed at the target bile ducts, i-stents or across stents were inserted at the desired bile ducts.…”

“…Since all patients were required to have more than two stents in this study, we aimed to drain the liver by more than 50% volume on MDCT and to avoid the atrophic areas. 15,16 Eventually, total bilirubin level could reduce less than 3mg/ dL for the following chemotherapy.…”

Efficacy and safety of EUS biliary drainage in malignant distal and hilar biliary obstruction: A comprehensive review of literature and algorithm

“…It is important to note that it has shown by achieving adequate drainage of >50% of liver segments correlates with better survival outcomes. [ 11 ]…”

Drainage of the right liver using EUS guidance

“…However, external drainage may not improve patient survival. [20] In complex drainage cases, the risk associated with an external drain increases in cases of percutaneous drainage. As a result, HDS can be advantageous in that a previous stent is placed.…”