Endoscopic biliary stenting combined with nasobiliary drainage in hilar malignant biliary obstruction.

Abstract

Background: There is no consensus on the optimal endoscopic drainage strategy for hilar malignant biliary obstruction (HMBO).

Objectives: To compare transpapillary plastic stent (PS) plus endoscopic nasobiliary drainage (ENBD) with PSs alone for HMBO, and to evaluate risk factors for cholangitis in the combined strategy group.

Design: Retrospective cohort study.

Methods: A total of 175 consecutive patients with HMBO (Bismuth type II-IV) who underwent either PS plus ENBD or PSs alone were enrolled. Propensity score matching (1:1) was performed to reduce selection bias. The primary endpoint was successful drainage. Univariate analysis was used to identify risk factors for cholangitis in the PS plus ENBD group.

Results: After matching, 74 patients remained in each group, with balanced baseline characteristics. Successful drainage rates were 77.0% in the PS plus ENBD group and 68.9% in the PSs alone group (p = 0.267). The PSs alone group had significantly higher rates of cholangitis (23.0% vs 10.8%, p = 0.048) and overall adverse events (29.7% vs 12.2%, p = 0.009). No significant differences were observed in biliary patency, reintervention, or survival time between groups. In the PS plus ENBD group, initial drainage was associated with cholangitis (100.0% vs 59.3%, p = 0.011), and median drainage volume was lower in patients who developed cholangitis (85 mL vs 250 mL, p = 0.021). In 19 patients, the nasobiliary catheter was snipped to convert external to internal drainage.

Conclusion: Endoscopic biliary stenting combined with ENBD followed by catheter snipping is a safe and effective approach for HMBO. The addition of ENBD was associated with reduced rates of cholangitis and overall adverse events. In this combined strategy, lack of initial drainage and low drainage volume were associated with cholangitis.