Efficacy of ≥ 50% biliary drainage in advanced unresectable malignant hilar biliary obstruction: A prospective study

Outcomes of drainage in hilar biliary obstruction may depend on volume of liver drained with previous studies showing better survival if more volume is drained. We aimed at determining the effect of draining > 50% of liver volume on clinical success after intervention in complex hilar blocks.

In this prospective observational study, advanced unresectable malignant hilar biliary obstruction with Bismuth-Corlette type II and above were recruited prospectively from October 2022 till April 2024. Patients underwent computed tomography (CT) abdomen and volumetric analysis using TeraRecon™ software. Patients were then subjected to endoscopic or percutaneous drainage. Based on intra-procedure details, patients were categorized into those achieving ≥ 50% (group A) and < 50% (group B) drainage groups. The primary outcome was clinical success. Secondary outcomes were complete drainage, cholangitis, reinterventions and overall survival.

Eighty patients (mean age 54.9 ± 13.59 years; 53.8% females) were analyzed in the study. Forty-eight patients (60%) underwent ≥ 50% drainage. Clinical success was achieved in 47 patients (58.75%). Clinical success was achieved in 35 out of 48 (72.9%) and 12 out of 32 (37.5%) in group A and B, respectively. Clinical success was significantly higher in the ≥ 50% drainage group (OR 3.411; p = 0.025), with lesser cholangitis (15% vs. 26.3%; p = 0.001), reinterventions (12.5% vs. 23.8%; p = 0.001) and improved 90-day survival (58.8% vs. 10%; p = 0.013). On multivariate analysis, clinical success was a significant predictor for lesser episodes of cholangitis, reduced reinterventions, with higher complete drainage.

More than or equal to 50% biliary drainage leads to better clinical success and improved 90-day survival, with lesser cholangitis and lesser biliary reintervention rate. CT volumetry acts as a guiding tool.