Endoscopic biliary drainage may be best in pancreatic cancer

Last Updated: 2015-10-30

By Larry Hand

NEW YORK (Reuters Health) - Endoscopic biliary drainage for malignant biliary obstruction should be first-line therapy for patients with pancreatic cancer, according to a new study.

Percutaneous drainage, however, still has a role in treating patients.

"This study is not meant to say we should only be doing endoscopic drainage. It is not meant to change management of patients," senior author Dr. Arvind J. Trindade, of Long Island Jewish Medical Center, New Hyde Park, New York, told Reuters Health in a telephone interview.

The study, he said, is intended to provide a stimulus for further research. Randomized controlled clinical trials are needed for further clarification.

Dr. Trindade and colleagues analyzed data from the National Inpatient Sample database on adverse events in people who underwent biliary drainage during 2007 through 2009. They compared adverse events associated with endoscopic retrograde cholangiopancreatography (ERCP) procedures with adverse events tied to percutaneous transhepatic biliary drainage (PTBD).

They included 7,445 patients who underwent ERCP and 1,690 patients who underwent PTBD in their analysis. The study population included adult hospitalized patients with malignant biliary tract obstruction and either pancreatic cancer or cholangiocarcinoma.

The groups were about evenly split regarding male and female patients, and 74% were white. Most patients had pancreatic cancer.

The researchers found an overall adverse event rate of 8.6% for ERCP and 12.3% for PTBD (p<0.001). For patients with pancreatic cancer, adverse events occurred in 2.9% of ERCP cases compared with 6.2% of PTBD cases (p<0.001). For cholangiocarcinoma patients, ERCP adverse events occurred in 2.6% of cases, compared with 4.2% of PTBD cases (p=0.1).

For pancreatic cancer, endoscopic procedures had lower adverse event rates regardless of the volume of percutaneous procedures performed at treatment centers.

However, for cholangiocarcinoma, in centers that performed a low volume of percutaneous procedures endoscopic adverse events were more likely to occur than in high-volume centers (5.7% vs. 2.5%, p=0.04). For centers performing a high volume of percutaneous procedures, adverse event rates were similar between procedures.

Costs of hospitalization for pancreatic cancer patients came to $73,151 for the PTBD procedures and $53,881 for the ERCP procedures, and $78,905 and $52,856, respectively, for cholangiocarcinoma patients. Patients who underwent PTBD also had longer lengths of stay.

"It's pretty obvious that for pancreatic cancer endoscopic is the way to go," Dr. Trindade said. But that doesn't mean percutaneous procedures should not be performed, he emphasized.

The main question for research now is 'Do certain types of obstruction make endoscopic or percutaneous procedures more preferable,' he said.

The numbers from the study also do not imply anything about clinical success, he said. "It doesn't mean that clinical success is higher for endoscopic."

"There's really a lack of literature looking at the optimal route. No one's really looked at adverse events of the two approaches" before this study, he added.

In their conclusion, the researchers say, "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 (randomized controlled trials) are still needed to expand on our experience and to address specific clinical scenarios."

Dr. Jimme K. Wiggers of the Academic Medical Center in Amsterdam, the Netherlands, who has studied biliary drainage, told Reuters Health by email, "Yes, there is absolutely a role for percutaneous drainage. Endoscopic drainage is the preferred drainage method for distal biliary obstructions, but proximal obstructions with involvement of the segmental bile ducts are difficult to drain endoscopically."

"Percutaneous drainage may be used in the palliative setting when endoscopic stents fail in patients with proximal obstructions," added Dr. Wiggers, who was not involved in the new research. "Moreover, percutaneous drainage is especially useful in the preoperative setting. Preoperative biliary drainage requires adequate drainage of the future liver remnant, so percutaneous drainage may help to drain specific segments of the liver in these cases, which endoscopic drainage cannot do."

The study authors reported no funding. One coauthor reported consulting for Boston Scientific.

SOURCE: http://bit.ly/1P0bmzs

JAMA Oncol 2015.