Comparison of long-term efficacy between endoscopic and percutaneous biliary drainage for resectable extrahepatic cholangiocarcinoma with biliary obstruction: A systematic review and meta-analysis

Diagnosis and Treatment of Perihilar Cholangiocarcinoma: A National Survey from the Korean Pancreatobiliary Association

Background/Aims

Based on their anatomy, cholangiocarcinomas (CCAs) are classified into intrahepatic, hilar, and distal CCAs. Although the diagnosis and treatment of each type of CCA are thought to be different, real-world data studies on the current practice are limited. Therefore, this study was designed to capture the current practice of diagnosing and treating perihilar CCA in Korea.

Methods

We conducted a survey using an online platform. The questionnaire consisted of 18 questions designed to evaluate the current practice of diagnosing and treating perihilar CCA in Korea. The targets of this survey were biliary endoscopists who are members of the Korean Pancreatobiliary Association.

Results

In total, 119 biliary endoscopists completed the survey. Of the respondents, 89.9% thought that the use of the International Classification of Diseases, 11th Revision (ICD-11) system is necessary to classify CCA. Approximately half of the respondents would recommend surgery or chemotherapy until patients were 80 years of age. For the pathological diagnosis of CCA, endoscopic retrograde cholangiopancreatography with biopsy was the most preferred modality. Routine preoperative biliary drainage was performed by 44.5% of the respondents. For operable CCAs, 64.7% of the respondents preferred endoscopic biliary drainage using plastic stents. For palliative biliary drainage, 69.7% of the respondents used plastic stents. For palliative endoscopic biliary drainage using metal stents, 63% of the respondents preferred the stent-in-stent method.

Conclusions

A new coding system using the ICD-11 is needed for classifying CCAs. Guidelines for diagnosing and treating CCA based on the clinical situation in Korea are needed.

Outcome of primary ERCP versus primary PTC for biliary drainage in malignant hilar biliary strictures: a systematic review and meta-analysis

BACKGROUND

Patients with malignant hilar biliary strictures can suffer from obstructive jaundice. Controversy remains on the optimal approach to obtain preoperative or palliative biliary drainage in these patients. A systematic review and meta-analysis was conducted to compare the two modalities most commonly used in this scenario: endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC).

METHODS

MEDLINE via PubMed was searched for relevant articles published from 2005 to April 2019. Following outcome measures were used to compare ERCP and PTC: therapeutic success rate, cholangitis, pancreatitis, bleeding, tube dislocation, reintervention rate, mortality such as 30d mortality and in-hospital death, median survival time, drainage patency, duration until decompression and hospital stay. Risk of bias assessment for the retrospective studies was conducted by NOS. RoB 2 was used for RCT. A meta-analysis was performed by using Review Manager 5.3. The certainty of evidence was appraised using GRADE.

RESULTS

Eleven articles of which one RCT and ten retrospective cohort studies fulfilled the inclusion criteria for data-analysis (1417 patients; 784 ERCP, 633 PTC). The combined odds ratio (OR) for therapeutic succes was 3.5 times higher in the PTC group (95% CI 2.05-5.97; high certainty). In terms of cholangitis, ERCP carried a 1.7-fold risk as compared to PTC (95% CI 0.92-3.08; moderate certainty). Patients who underwent ERCP were 11.50 times more likely to undergo a reintervention (95% CI 3.51-37.70; moderate certainty). ERCP was comparable to PTC in terms of pancreatitis (low certainty), bleeding (high certainty) and tube dislocation rate (moderate certainty). Mortality tended to be numerically higher in the PTC group but low patient numbers, selection bias and study heterogeneity did not allow uniform comparative analysis.

CONCLUSIONS

In patients with malignant hilar biliary strictures, PTC is associated with a better therapeutic success rate, less cholangitis and lower reintervention rate as compared to ERCP.

[Preoperative biliary drainage for malignant biliary obstruction: to drain or not to drain? And if drain, in what way?]

On the basis of the conducted literary search, a number of conclusions can be drawn. When performing preoperative biliary drainage (PBD), it is necessary to have a clear understanding: why is this procedure performed (severe liver failure, cholangitis, long preoperative preparation is required due to comorbid status, neoadjuvant chemotherapy is necessary, etc.)? Routine use of PBD is impractical. In the presence of indications for PBB in perihilar cholangiocarcinoma, percutaneous decompression is preferable, in periampullary tumors, endoscopic. Moreover, both methods can be alternative (for example, in case of technical failure of the first priority). There is also no convincing evidence of the superiority of metal stents over plastic ones for PBD (except in cases of long-term preoperative preparation or neoadjuvate treatment) for periampular tumors. To date, a decrease in overall survival and a higher incidence of implantation metastases have not been proven when using the antegrade PBD method. Large multicenter studies are required with differentiation of patients according to the nosological principle in order to more accurately understand the place of each method, as well as to determine clear indications for PBD and those clinical situations when its implementation is impractical.

Adverse oncologic effects of preoperative biliary drainage on early stage ampulla of Vater cancer

BACKGROUND

The preoperative biliary drainage (PBD) in ampulla of Vater (AoV) cancer is indiscriminately performed without logical backgrounds. This study was performed to evaluate the effect of PBD on short and long-term outcomes in AoV cancer.

METHODS

313 patients who underwent pancreaticoduodenectomy and were pathologically diagnosed as AoV cancer between January 2000 and December 2014 were reviewed.

RESULTS

167 patients (53.4%) underwent PBD: Endoscopic drainage was performed in 106 patients (33.9%) and percutaneous drainage in 61 (19.5%). The postoperative complication rate of PBD group was significantly higher than that of upfront surgery group (48.5% vs. 38.4%, p = 0.045). The 5-year disease-free survival rate (5Y-DFSR) was significantly lower in PBD group compared to upfront surgery group (53.8% vs. 74.3%, p < 0.001). Worse 5Y-DFSR of PBD group was more evident in T1/T2 stage (59.2% vs. 84.1%, p < 0.001). In multivariate analysis with T1/T2 staged patients, PBD was independently associated with worse outcome (hazard ratio 2.145 [95% confidence interval, 1.202-3.826], p = 0.010).

CONCLUSION

For T1/T2 AoV cancer, PBD adversely affected the short-term postoperative complication rate as well as the long-term oncologic outcomes. Therefore, especially in patients with T1/T2 AoV cancer, routine practice of PBD should be refrained and be reserved for selected cases such as cholangitis.

Italian Clinical Practice Guidelines on Cholangiocarcinoma - Part II: Treatment

Currently, the only curative treatment for cholangiocarcinoma (CCA) is surgical resection, though this treatment is possible in less than 40% of patients. However, recent improvements in preoperative management have led to a higher number of patients who are candidates for this procedure. For unresectable patients, progress is ongoing in terms of locoregional and chemoradiation treatments and target therapies, especially in the definition of patient selection criteria. This is the second part of the Italian CCA guidelines, dealing with CCA treatment, that have been formulated in accordance with Italian National Institute of Health indications and developed according to the GRADE method and related advancements.

A systematic review of the comparison of the incidence of seeding metastasis between endoscopic biliary drainage and percutaneous transhepatic biliary drainage for resectable malignant biliary obstruction

BACKGROUND AND AIM

Endoscopic biliary drainage (EBD) and percutaneous biliary drainage (PTBD) are the two main strategies of preoperative biliary drainage (PBD) for resectable malignant biliary obstruction (MBO) worldwide, but which is better remains unclear. Seeding metastasis (SM) has been reported repeatedly in the recent decade, although it is rarely taken into consideration in the choice of PBD. Hence, a systematic review was badly warranted to evaluate the incidence of SM between PTBD and EBD in the preoperative treatment of MBO.

METHODS

PubMed, MEDLINE, the Cochrane Library, and Web of Science were used to identify any potentially eligible studies comparing the incidence of SM between EBD and PTBD from Nov 1990 to Mar 2018. The effect size was determined by odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Ten studies were enrolled in this study, including 1379 cases in the EBD group and 1085 cases in the PTBD group. Results showed that the incidence of SM in the EBD group was significantly lower than that in the PTBD group (10.5% vs. 22.0%, OR = 0.35, 95% CI 0.23~0.53). Subgroup analysis stratified by the definition of SM showed that the pooled ORs for peritoneal metastasis and tube-related SM between EBD and PTBD were 0.42 (95% CI 0.31~0.57) and 0.17 (95% CI 0.10~0.29), respectively. Subgroup analysis stratified by the location of MBO showed that the pooled ORs for the incidence of SM between EBD and PTBD for perihilar cholangiocarcinoma, distal cholangiocarcinoma, and pancreatic cancer were 0.27 (95% CI 0.13~0.56), 0.32 (95% CI 0.17~0.60), and 0.27 (95% CI 0.19~0.40), respectively.

CONCLUSION

EBD should be the optimal PBD for MBO considering the SM, but it deserved further validation.