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

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.

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.

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).

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.