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Sunday Poster Session

Category: Biliary/Pancreas

P0046 - Biliary Drainage in Perihilar Cholangiocarcinoma - 25 Year Experience at a Large US Tertiary Cancer Center

Sunday, October 22, 2023
3:30 PM – 7:00 PM PT
Location: Exhibit Hall
Has Audio
ACG Outstanding Poster Presenter
Ahmad Nakshabandi, MD1, Faisal Ali, MD1, Iyad S.. Al-Bustami, MD2, Nicole Johnston, MD1, Abdullah Shaikh, MD3, Daniel J. Low, MD3, William A Ross, MD3, Brian R. Weston, MD3, Phillip Ge, MD3, Emmanuel Coronel, MD3, Jeffrey H. Lee, MD, MPH3
1UT MD Anderson Cancer Center, Houston, TX; 2University of Texas Health Science Center at Houston, Houston, TX; 3University of Texas MD Anderson Cancer Center, Houston, TX

Introduction: The optimal stent type for biliary drainage in cholangiocarcinoma (CCA) is not established.

Methods: This is a retrospective study of patients with CCA from 1997-2023, excluding Bismuth class 1, who underwent biliary drainage at a cancer center. A per-patient analysis of percutaneous biliary drainage (PBD) rates, median number of ERCPs, overall survival (OS), and a per-procedure analysis of clinical success (CS), stent specific complications (SSCs), and mean time to reintervention by stent type and laterality (u vs b) is presented.

Results: Overall, 333 patients underwent 1,127 ERCPs (85% with plastic stents (PS)); PBD was done in 23% of PS patients; 35% had PS removed pre-PBD. ERCPs with SEMS and uSEMS use had higher CS (89%/91%) vs PS/uPS (85% both) and PS within SEMS (PS-SEMS)/uPS-SEMS (71%/74%;p=0.054); PS-SEMS were associated with poorer CS vs PS (OR 0.35;0.15-0.80;p=0.013). More SSCs were noted in SEMS (uSEMS 57%/bSEMS 41%) and PS-SEMS arms (uPS-SEMS 74%/bPS-SEMS 60%;p< 0.001); both were associated with higher SSCs vs PS (OR SEMS 4.85;3.23-7.27; PS-SEMS 9.99;5.33-18.71;p< 0.001). Straight PS were associated with more SSCs vs double-pigtail stents (DPT;OR 6.74;3.95-11.45;p< 0.001). Liver atrophy, pus on ERCP, higher Bismuth class, less CS, PS use, and PS-SEMS use were associated with shorter mean time to repeat ERCP. Balloon dilation (BD) was done in 48% of ERCPs with Bismuth 4 disease. Bilateral stenting was done in 53% of ERCPs with BD. PS were placed in 90% after BD; 41% were DPT; more 7 Fr stents were used (109 vs 88 with no BD;p< 0.001). CS was 79% with BD versus 87% without BD (p< 0.001).

Radiotherapy, total ERCPs/ PBDs & internalization of external PBDs were associated with improved OS; 52% of patients in the bSEMS arm had death from cholangitis (DFC) vs uSEMS (32%;p=0.005), with no difference in uPS vs bPS. There was no significant difference in DFC on competing risk analysis stratified by stent type or PBD status.

Discussion: The higher CS with SEMS use comes at the cost of higher SSCs, and potentially higher DFC (with bSEMS). PS removal to facilitate PBD is an advantage over SEMS. DPTs have less SSCs than straight PS. The mean time to repeat ERCP was shorter with PS use, but without difference in number of ERCPs per patient. BD should be utilized to aid in stenting tight strictures. Pus on ERCP and liver atrophy may have predictive potential for time to reintervention

Figure: Schematic of Per-Patient and Per-Procedure Analysis Structure

Characteristics and Outcomes of Biliary Drainage in Peri-Hilar Cholangiocarcinoma – Per-Procedure Analysis


Variables

Unilateral Stents

Bilateral Stents

Plastic
Stents

Metal
Stents

Plastic in Metal Stents

p-value

Plastic Stents

Metal Stents

Plastic in Metal Stents

p-value

Indication for ERCP, n (%)

Cholangitis

73
(14.3)

16
(19)

10
(28.6)

0.022

60
(16)

2
(6.9)

2
(13.3)

< 0.001

Stent Exchange

222
(43.4)

24
(28.6)

11
(31.4)

209
(55.7)

8
(27.6)

5
(33.3)

Hyperbilirubinemia without Cholangitis

216
(42.3)

44
(52.4)

14
(40)

106
(28.3)

19
(65.5)

8
(53.3)

Pus on ERCP, n(%)

63
(12.35)

14
(16.67)

12
(35.29)

0.001

66
(17.55)

6
(20.69)

3
(20)

0.892

Liver Atrophy, n(%)

221
(44.8)

28
(35.4)

15
(44.12)

0.295

117
(31.7)

11
(39.3)

3
(21.4)

0.492

Balloon Dilation, n(%)

350
(68.6)

72
(85.7)

24
(70.6)

0.006

185
(49.2)

10
(34.5)

8
(53.3)

0.288

Balloon Dilation Pattern, n(%)

Unilateral Balloon Dilation

135
(88.2)

9
(75)

9
(100)

0.208

70
(38.25)

3
(30)

5
(62.5)

0.326

Bilateral Balloon Dilation

3
(25)

18
(11.7)

0 (0)

113
(61.75)

7
(70)

3
(37.5)

Technical Success, n(%)

510

(99.8)

84
(100)

35
(100)

NS

376
(100)

29
(100)

15
(100)

NS

Clinical Success, n(%)

424
(84.5)

72
(91.1%)

25
(73.5)

0.054

313
(84.6)

25
(86.2)

10
(66.6)

0.168

Adverse Events, n(%)

112
(21.9)

48
(57.1)

26
(74.3)

< 0.001

56
(14.9)

12
(41.3)

9
(60)

< 0.001

Change in Bilirubin After ERCP, mean (SD)

0.04
(1.10)

0.07
(1.51)

0.07 (0.70)

NS

0.01
(1.13)

0.35
(0.42)

0.22
(0.95)

NS

Time to repeat ERCP (days), mean (SD)

72.6
(85.3)

250.8
(46)

57.4
(29.2)

NS

75.4
(43.0)

133.8

(136.1)

48.5
(29.4)

NS

Univariate and Multivariate Regression – Mean Time to Repeat ERCP

Univariate Analysis, Coef (p-value)

Univariate Analysis, Coef (p-value)

Liver Atrophy

      Yes

-23.01 (0.005)

-15.76 (0.002)

Pus on ERCP

     Yes

     -18.4 (0.09)

     -15.71 (0.092)

Bismuth Classification

      2

Ref

 

      3a

-43.6 (< 0.001)

-34.1 (< 0.001)

      3b

-34.1 (0.001)

-30.81 (0.001)

      4

-42.8 (< 0.001)

-33.93 (< 0.001)

Balloon Dilation

      Yes 

-14.33 (0.074)

 

Clinical Success

      Yes

52.2 (< 0.001)

43.2 (< 0.001)

Adverse Events

      Yes

11.72 (0.193)

 

Stent Categories

   Plastic Stents

-143.9 (< 0.001)

-145.3 (< 0.001)

Plastic Stents within Metal Stents

-163.5 (< 0.001)

-147.7 (< 0.001)

Univariate and Multivariate Regression – Stent Specific Complications

Univariate Analysis, Coef (p-value)

Multivariate Analysis , Coef (p-value)

Liver Atrophy

      Yes

1.613 (1.216, 2.140; 0.001)

 

Pus on ERCP

     Yes

1.6683 (1.1712, 2.3764; 0.005)

1.9466 (1.0940, 3.4634; 0.023)

Bismuth Classification

       2

Ref 

 

      3a

0.6527 (0.4247, 1.0031; 0.052)

 

      3b

0.6720 (0.4612, 0.9792;  0.039)

 

      4

0.9870 (0.6911, 1.4094; 0.942)

 

Balloon Dilation

      Yes 

0.6390 (0.4743, 0.8609; 0.003)

 

Time to Repeat ERCP

      

1.001 (0.9995, 1.002; 0.201)

1.0025 (1.0000, 1.0050; 0.049)

Clinical Success

      Yes

0.961 (0.662, 1.396; 0.834)

 

Stent Categories

Metal Stents

Ref

 

Plastic Stents

0.2064 (0.138, 0.310; < 0.001)

 

Plastic Stents within Metal Stents

2.061 (1.015, 4.187; 0.046)

 

Univariate and Multivariate Regression – Clinical Success of ERCP

Univariate Analysis, Coef (p-value)

Multivariate Analysis , Coef (p-value)

Liver Atrophy

      Yes

1.0074 (0.7123 - 1.428; 0.967)

 

Pus on ERCP

     Yes

0.8023 (0.5188 - 1.2407; 0.322)

 

Bismuth Classification

       2

Ref

 

      3a

0.635 (0.372-1.086; 0.097)

 

      3b

0.613 (0.378 - 0.993; 0.047)

 

      4

0.490 (0.306 - 0.783; 0.003)

 

Balloon Dilation

      Yes 

0.526 (0.377 - 0.734; 0.000)

0.5448 (0.3312, 0.8960; 0.017)

Time to Repeat ERCP

      

1.034 (1.026 - 1.043; < 0.001)

1.032 (1.023, 1.041; < 0.001)

Adverse Events

      Yes

0.961 (0.662 - 1.396; 0.834)

 

Stent Categories

      Metal Stents

Ref

 

      Plastic Stents

0.619 (0.323 - 1.186; 0.148)

2.2625 (0.7199, 7.1105; 0.162)

      Plastic Stents in Metal Stents

0.284 (0.118 - 0.68; 0.005)

0.7836 (0.1997, 3.0753; 0.727)

      Plastic Stents

Ref 

 

      Plastic Stents in Metal Stents

0.458 (0.240, 0.874; 0.018)

0.346 (0.150, 0.798; 0.013)

 


Table: Characteristics and Outcomes of Biliary Drainage in Peri-Hilar Cholangiocarcinoma – Per-Procedure Analysis


Disclosures:
Ahmad Nakshabandi indicated no relevant financial relationships.
Faisal Ali indicated no relevant financial relationships.
Iyad Al-Bustami indicated no relevant financial relationships.
Nicole Johnston indicated no relevant financial relationships.
Abdullah Shaikh indicated no relevant financial relationships.
Daniel Low indicated no relevant financial relationships.
William A Ross indicated no relevant financial relationships.
Brian Weston indicated no relevant financial relationships.
Phillip Ge: Alira Health – Consultant. Boston Scientific – Consultant. Neptune Medical – Consultant. Ovesco America – Consultant.
Emmanuel Coronel indicated no relevant financial relationships.
Jeffrey Lee: Boston Scientific – Consultant. Pentax – Consultant.


Ahmad Nakshabandi, MD1, Faisal Ali, MD1, Iyad S.. Al-Bustami, MD2, Nicole Johnston, MD1, Abdullah Shaikh, MD3, Daniel J. Low, MD3, William A Ross, MD3, Brian R. Weston, MD3, Phillip Ge, MD3, Emmanuel Coronel, MD3, Jeffrey H. Lee, MD, MPH3. P0046 - Biliary Drainage in Perihilar Cholangiocarcinoma - 25 Year Experience at a Large US Tertiary Cancer Center, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.