Endoscopic or percutaneous biliary drainage for Klatskin tumors?

PURPOSE

Controversy exists regarding the preferred biliary drainage technique in patients with Klatskin tumors because few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).

MATERIALS AND METHODS

Consecutive patients (N = 129) with Klatskin tumors treated with initial EBD or PTBD were identified, and their clinical histories were retrospectively reviewed. The primary endpoint was the time to therapeutic success (TTS), defined as the time between the first drainage and a total bilirubin measurement of 40 μmol/L or lower.

RESULTS

EBD was the first biliary decompression procedure performed in 87 patients; PTBD was performed first in 42. Technical success rates (78% with EBD vs 98% with PTBD; P = .004) and therapeutic success rates (49% vs 79%, respectively; P = .002) were significantly lower in the EBD group than in the PTBD group. Forty-four patients in the EBD group (51%) subsequently underwent PTBD before therapeutic success was achieved or antitumoral treatment was started. Median TTSs were 61 days in the EBD group and 44 days in the PTBD group, and multivariate analysis showed a hazard ratio of 0.63 (95% confidence interval, 0.41-0.99; P = .045). In patients treated with surgery or chemotherapy with or without radiation therapy, median times to treatment were 76 and 68 days in the EBD and PTBD groups, respectively (P = .76). Cholangitis occurred in 25% and 21% of patients in the EBD and PTBD groups, respectively (P = .34).

CONCLUSIONS

PTBD should be seriously considered for biliary decompression when treating patients with Klatskin tumor.

Endoscopic or percutaneous biliary drainage for Klatskin tumors? A large retrospective study

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Background: Controversy exists over the preferred technique of biliary drainage in patients with Klatskin tumors as few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).

Methods: 129 patients with Klatskin tumors with an initial EBD or PTBD were identified from 01/01/1991 to 31/05/2011 and their clinical histories were retrospectively reviewed. The primary end point was the time to therapeutic success (TTS: time between the first drainage and a total bilirubin<40µmol/L), estimated by Kaplan-Meier analysis.

Results: The first biliary decompression procedure was EBD in 87 patients and PTBD in 42 patients. The technical (98% vs 78%, p=0.004) and therapeutic (79% vs 49%, p=0.002) successes were significantly higher in the PTBD group than EBD group, respectively; Forty four patients (51%) in the EBD group subsequently underwent a PTBD before achieving therapeutic success or starting their antitumoral treatment. The median TTS was 55 days in EBD group vs 44 days in the PTBD group (multivariate analysis: HR=0.63, 95% CI=0.41-0.99, p=0.045). In patients treated by surgery or chemotherapy +/− radiotherapy, the median time to treatment was 68 and 76 days in the PTBD group and the EBD group, respectively, p=0.76. 25% and 21% of cholangitis occurred in EBD and PTBD group, respectively (p=0.34).

Conclusions: In the era where chemotherapy prolongs life even in advanced disease, shortening time to success matters. Our results suggest relying on PTB for biliary decompression would be an improved treatment strategy when treating patients with Klatskin tumor.