Outcomes and complications of biliary drainage for malignant biliary obstruction: National prospective study.

Abstract

Background and study aims: National data suggest that biliary drainage for malignant obstruction is associated with high complication rates and early mortality. This study examined factors associated with poor outcomes.

Patients and methods: RICOCHET was a national, prospective audit of patients with pancreatic cancer or malignant biliary obstruction between April and August 2018. This analysis reviewed outcomes including complications within 7 days and 30-day mortality following biliary drainage and associated factors.

Results: Biliary drainage was attempted in 773 patients, of which, 78.7% were successful at first attempt; but if unsuccessful, only 37% of subsequent attempts succeeded. Complications occurred following 11% of endoscopic retrograde cholangiopancreatographies (ERCPs) (including pancreatitis, 5%) and 12% of percutaneous transhepatic biliary drainages (PTBDs) (including cholangitis, 8%). Complications were associated with: potentially resectable cancer (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.23-3.03); more than one biliary drainage attempt (OR 1.69, 95% CI 1.04-2.74); cholangiocarcinoma (OR 2.20, 95% CI 1.20-4.05), or radiological cancer diagnosis (OR 2.02, 95% CI 1.13-3.60). Thirty-day mortality rates following ERCP and PTBD were 21.4% and 21.4%, respectively, in unresectable cancer and 6% and 6.3%, respectively, in potentially resectable cancer. Increased 30-day mortality in patients with unresectable disease was associated with a performance status of 2 or more (HR 3.14 (1.65-5.97)). Thirty-day mortality was significantly higher in patients with unresectable cancer if a multidisciplinary team meeting had not reviewed and advised drainage prior to the procedure 50% vs 20.4% ( P = 0.028).

Conclusions: Careful multidisciplinary consideration of risks and potential benefits should be undertaken prior to attempting malignant biliary drainage due to the high risk of complications and early mortality.