Outcomes of salvage percutaneous biliary drainage for malignant obstruction after failure of endoscopic stenting

PurposeTo describe the outcomes of patients with malignant biliary obstruction who undergo salvage percutaneous biliary drainage after failure of endoscopic biliary stents.Materials47 patients underwent salvage percutaneous biliary drainage for recurrent malignant obstruction after endoscopic stenting at a single institution between 2005-2015. The medical records were reviewed for demographic data, procedural information, laboratory data, 30 day complications and subsequent biliary procedures. Cox regression, t-tests and summary statistics were performed to identify factors that contributed to patient outcome.ResultsThe study group median age was 61 (range 33-83) and was comprised of 25 men (53%). Underlying malignancies included cholangiocarcinoma (n=13), colorectal (n=11), gallbladder (n=7), pancreatic (n=5), hepatocellular (n=4), and other (n=7). 24 patients had metallic endoscopic stents, 22 patients had plastic endoscopic stents, and one had both. Median time from endoscopic stenting to percutaneous drain placement was 39 days (range 1-824). Bismuth classification of the lesions included 5 type I, 3 type II, 2 type III, and 37 type IV. Percutaneous drainage procedures included placement of external drains (n=14), internal-external drains (n=28), internal-external and external drain (n=3), and metallic stent (n=2). There were nine major procedure related complications at 30 days including sepsis (n=4), tube dislodgement (n=4), bleeding (n=1). Mean number of repeat biliary procedures was 1.9 per 100 catheter-days. Median survival post salvage biliary drain placement was less than 2 months. 15 patients (32%) went on to receive additional chemotherapy after salvage biliary drain placement. 11 patients (23%) survived more than 5 months (range 162-556 days). Higher international normalized ratio (INR) prior to salvage drain placement predicted poor post-procedure outcome (p<0.05).ConclusionsWhile selected patients benefit from salvage percutaneous biliary drainage, the majority of patients who undergo this procedure have limited survival. Elevated pre-procedure INR is predictive of poor short term outcomes. Patients should be carefully selected prior to undergoing this procedure. PurposeTo describe the outcomes of patients with malignant biliary obstruction who undergo salvage percutaneous biliary drainage after failure of endoscopic biliary stents. To describe the outcomes of patients with malignant biliary obstruction who undergo salvage percutaneous biliary drainage after failure of endoscopic biliary stents. Materials47 patients underwent salvage percutaneous biliary drainage for recurrent malignant obstruction after endoscopic stenting at a single institution between 2005-2015. The medical records were reviewed for demographic data, procedural information, laboratory data, 30 day complications and subsequent biliary procedures. Cox regression, t-tests and summary statistics were performed to identify factors that contributed to patient outcome. 47 patients underwent salvage percutaneous biliary drainage for recurrent malignant obstruction after endoscopic stenting at a single institution between 2005-2015. The medical records were reviewed for demographic data, procedural information, laboratory data, 30 day complications and subsequent biliary procedures. Cox regression, t-tests and summary statistics were performed to identify factors that contributed to patient outcome. ResultsThe study group median age was 61 (range 33-83) and was comprised of 25 men (53%). Underlying malignancies included cholangiocarcinoma (n=13), colorectal (n=11), gallbladder (n=7), pancreatic (n=5), hepatocellular (n=4), and other (n=7). 24 patients had metallic endoscopic stents, 22 patients had plastic endoscopic stents, and one had both. Median time from endoscopic stenting to percutaneous drain placement was 39 days (range 1-824). Bismuth classification of the lesions included 5 type I, 3 type II, 2 type III, and 37 type IV. Percutaneous drainage procedures included placement of external drains (n=14), internal-external drains (n=28), internal-external and external drain (n=3), and metallic stent (n=2). There were nine major procedure related complications at 30 days including sepsis (n=4), tube dislodgement (n=4), bleeding (n=1). Mean number of repeat biliary procedures was 1.9 per 100 catheter-days. Median survival post salvage biliary drain placement was less than 2 months. 15 patients (32%) went on to receive additional chemotherapy after salvage biliary drain placement. 11 patients (23%) survived more than 5 months (range 162-556 days). Higher international normalized ratio (INR) prior to salvage drain placement predicted poor post-procedure outcome (p<0.05). The study group median age was 61 (range 33-83) and was comprised of 25 men (53%). Underlying malignancies included cholangiocarcinoma (n=13), colorectal (n=11), gallbladder (n=7), pancreatic (n=5), hepatocellular (n=4), and other (n=7). 24 patients had metallic endoscopic stents, 22 patients had plastic endoscopic stents, and one had both. Median time from endoscopic stenting to percutaneous drain placement was 39 days (range 1-824). Bismuth classification of the lesions included 5 type I, 3 type II, 2 type III, and 37 type IV. Percutaneous drainage procedures included placement of external drains (n=14), internal-external drains (n=28), internal-external and external drain (n=3), and metallic stent (n=2). There were nine major procedure related complications at 30 days including sepsis (n=4), tube dislodgement (n=4), bleeding (n=1). Mean number of repeat biliary procedures was 1.9 per 100 catheter-days. Median survival post salvage biliary drain placement was less than 2 months. 15 patients (32%) went on to receive additional chemotherapy after salvage biliary drain placement. 11 patients (23%) survived more than 5 months (range 162-556 days). Higher international normalized ratio (INR) prior to salvage drain placement predicted poor post-procedure outcome (p<0.05). ConclusionsWhile selected patients benefit from salvage percutaneous biliary drainage, the majority of patients who undergo this procedure have limited survival. Elevated pre-procedure INR is predictive of poor short term outcomes. Patients should be carefully selected prior to undergoing this procedure. While selected patients benefit from salvage percutaneous biliary drainage, the majority of patients who undergo this procedure have limited survival. Elevated pre-procedure INR is predictive of poor short term outcomes. Patients should be carefully selected prior to undergoing this procedure.