The outcomes of biliary drainage by percutaneous transhepatic cholangiography for the palliation of malignant biliary obstruction in England between 2001 and 2014: a retrospective cohort study

Abstract

IntroductionRelieving obstructive jaundice in inoperable pancreato-biliary cancers improves quality of life and permits chemotherapy. Percutaneous transhepatic cholangiography with drainage and/or stenting relieves jaundice but can be associated with significant morbidity and mortality. Percutaneous transhepatic biliary drainage (PTBD) in malignant biliary obstruction was therefore examined in a national cohort to establish risk factors for poor outcomes.MethodsRetrospective study of adult patients undergoing PTBD for palliation of pancreato-biliary cancer in England between 2001 and 2014 identified from Hospital Episode Statistics. Multivariate logistic regression analysis was used to examine associations with mortality and the need for a repeat PTBD within 2 months.Results16 822 patients analysed (median age 72 (range 19–104) years, 50.3% men). 58% pancreatic and 30% biliary tract cancer. In-hospital and 30-day mortality were 15.3% (95% CI 14.7% to 15.9%) and 23.1% (22.4%–23.8%), respectively. 20.2% suffered a coded complication within 3 months. Factors associated with 30-day mortality: age (≥81 years OR 2.68 (95% CI 2.37 to 3.03), p<0.001), increasing comorbidity (Charlson score 20+, 3.10 (2.64–3.65), p<0.001), pre-existing renal dysfunction (2.37 (2.12–2.65), p<0.001) and non-pancreatic cancer (unspecified biliary tract 1.28 (1.08–1.52), p=0.004). Women had lower mortality (0.91 (0.84–0.98), p=0.011), as did patients undergoing PTBD in a ‘higher volume’ provider (84–180 PTBDs per year 0.68 (0.58–0.79), p<0.001).ConclusionsIn patients undergoing PTBD for the palliation of malignant biliary obstruction, 30-day mortality was high at 23.1%. Mortality was higher in older patients, men, those with increasing comorbidity, a cancer site other than pancreas and at ‘lower-volume’ PTBD providers.

Characteristics and Outcomes of Percutaneous Biliary Interventions in the United States

“…In contrast, in a study of patients requiring biliary drainage using the national readmission database by Parikh et al more than 70% of had routine discharge [14]. Patients with more comorbidities and worse disease severity were more likely to need PBIs as opposed to a surgical or endoscopic procedure [8,14]. More than one-third of patients in our study sample had more than three underlying comorbidities (35.8% AE 0.8%) with an estimated 6.1% AE 0.6% inpatient mortality rate.…”

“…The mortality rate after PBIs seems to be highly variable within the literature and may be largely driven by the underlying diagnosis. Depending on the clinical indication, the mortality after PBIs can be as low as 2% and as high as 20% in selected patients [8,15]. Moreover, 30-day mortality may be as high as 39% in patients undergoing palliative treatment [16].…”

“…In addition to their diagnostic utility, PBI also allows for a plethora of therapeutic interventions that include draining infected bile secondary to cholangitis, dilating or stenting biliary strictures, and removing biliary stones [1,5,7]. Though endoscopic retrograde cholangiopancreatography (ERCP) and MR cholangiopancreatography are used to diagnose and treat many of the same biliary pathologies, a percutaneous approach with PTC or PBD remains an attractive option, especially when ERCP has failed or is not feasible (eg, in patients with gastrojejunostomy, or inability to cannulate the sphincter of Oddi) [5,7,8].…”

EUS-guided choledochoduodenostomy as a rescue after failed ERCP and percutaneous transhepatic biliary drainage in the management of postoperative benign biliary stricture

“…PTBD is generally considered as a fallback option after failed ERCP, which is associated with significant adverse events. 2 Postcholecystectomy bile duct injuries are a common cause of benign biliary obstruction (BBO) that are usually addressed effectively by ERCP. 3 Untreated BBO, apart from cholangitis and pruritus, carries a risk of progression to secondary biliary cirrhosis.…”

The role of endoscopic ultrasound guidance for biliary and pancreatic duct access and drainage to overcome the limitations of ERCP: a retrospective evaluation

“…In select patients, PTBD is preferred to ERCP for primary biliary drainage. Forty percent of patients with biliary malignancy who undergo PTBD have no prior ERCP attempts [2]. Additionally, complementary percutaneous intervention may be required after successful ERCP.…”