Fewer Adverse Events with Endoscopic Versus Percutaneous Drainage in Malignant Biliary Disorders

US study findings support the use of endoscopic rather than percutaneous biliary drainage as a first-line intervention in patients with malignant biliary tract obstruction

medwireNews: Endoscopic biliary drainage is associated with fewer procedure-related adverse events than percutaneous drainage in patients with malignant biliary tract obstruction, a study shows.

This remains the case in the subgroup of pancreatic cancer patients irrespective of centre expertise, but for those with cholangiocarcinoma, endoscopic drainage is “superior” only in hospitals that perform a low volume of percutaneous drainage procedures, say the study authors.

They used the Nationwide Inpatient Sample database to identify 7445 patients with malignant biliary tract obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) and 1690 treated with percutaneous transhepatic biliary drainage (PTBD) between 2007 and 2009.

Overall, procedure-related adverse events – such as haemorrhage and perforation for both procedures, pancreatitis for ERCP, and peritonitis and/or bile leak for PTBD – occurred significantly less frequently in the ERCP compared with the PTBD group, at 8.6% versus 12.3%.

ERCP remained significantly associated with a lower adverse event rate compared with PTBD in patients with pancreatic cancer (2.9 vs 6.2%), including in low- and high-volume facilities for PTBD (2.9 vs 7.6% and 3.1 vs 5.6%, respectively), where the latter were those where PTBD accounted for at least 20% of drainage procedures performed for malignant biliary disorders.

Among cholangiocarcinoma patients, the ERCP and PTBD groups were comparable with respect to the incidence of side effects overall and in high-volume centres for PTBD. But in low-volume PTBD facilities, patients who underwent ERCP experienced significantly fewer side effects than PTBD-treated patients (2.5 vs 5.7%).

Researcher Arvind Trindade, from Hofstra North Shore-LIJ School of Medicine in New York, USA, and co-workers write that “[w]hile we believe the data in the pancreatic cancer subgroup are robust, we would advise a word of caution in regard to the cholangiocarcinoma subgroup”, as they could not determine factors such as tumour stage and Bismuth classification owing to dataset limitations.

Nonetheless, they conclude in JAMA Oncology: “Our data support the contention that ERCP should be the first-line treatment consideration for [malignant biliary tract obstruction] in pancreatic cancer and low-volume centers for PTBD in cholangiocarcinoma.

“Larger prospective [randomised controlled trials] are still needed to expand on our experience and to address specific clinical scenarios (eg, hilar cholangiocarcinoma).”


Inamdar S, Slattery E, Bhalla R, Sejpal DV, Trindade AJ. Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort.JAMA Oncol 2015; Advance online publication 29 October. doi:10.1001/jamaoncol.2015.3670

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