Conference Coverage

Percutaneous drainage upped morbidity risk in hepatobiliary cancer patients



– In patients with resectable hepatobiliary malignancies, percutaneous biliary drainage was associated with an increased risk of death or serious morbidity versus endoscopic drainage, results of a recent retrospective study show.

Illustration of the liver decade3d/

Patients undergoing percutaneous transhepatic biliary drainage did have more preoperative comorbidities, compared with those undergoing endoscopic biliary stenting, according researcher Q. Lina Hu, MD, an American College of Surgeons Clinical Scholar-in-Residence.

“Nevertheless, compared to endoscopic drainage, percutaneous drainage was associated with a significantly increased morbidity and mortality, even after adjustment for measured confounders,” Dr. Hu said a presentation at the American College of Surgeons Quality and Safety Conference.

Patients with resectable hepatobiliary malignancies often present with biliary obstruction, which may increase risk of perioperative morbidity and mortality, said Dr. Hu, a general surgery resident at University of California, Los Angeles.

“Preoperative biliary drainage is thought to reduce this risk by resolving cholestasis and preserving liver function,” she said.

However, the preferred drainage technique is not established, she added.

The endoscopic approach approximates normal physiologic drainage, she said, but is associated with complications including pancreatitis and cholangitis. By contrast, percutaneous drainage has a lower contamination risk and higher rate of success, but involves external catheters and has catheter-related complications.

To evaluate associations between preoperative drainage technique and postoperative outcomes, Dr. Hu and her colleagues queried the ACS National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Hepatectomy Database. They identified 527 patients who underwent preoperative biliary drainage prior to resection between 2014 and 2017, of whom about 80% underwent endoscopic drainage and 20% underwent percutaneous drainage. The primary outcome of their analysis was 30-day death or serious morbidity.

Patients who were selected for percutaneous drainage had significantly more preoperative comorbidities, including higher American Society of Anesthesiologists class, recent weight loss, and lower albumin levels, Dr. Hu said.

Death or serious morbidity occurred in 250 of the patients, or approximately 48% of the cohort.

In unadjusted analysis, the incidence of death or serious morbidity was significantly more frequent in the percutaneous group, compared with endoscopic group. The percutaneous group also had greater odds of surgical site infection, liver failure, bile leakage, and prolonged length of stay.

Those associations remained significant for death or serious morbidity and surgical site infection in both multivariable– and propensity score–adjusted models, Dr. Hu said.

In a propensity score–matched model, 93 patients who received percutaneous drainage were matched one-to-one to 93 patients who received endoscopic drainage based on relevant baseline characteristics. In that rigorous analysis, the odds ratio for death or serious morbidity was 2.17 (95% confidence interval, 1.16-4.09), according to the report.

“Death and serious morbidity was significantly associated with percutaneous drainage across all models, suggesting that patients receiving percutaneous drainage were more likely to experience an adverse event, compared to patients receiving endoscopic drainage,” Dr. Hu said.

However, Dr. Hu acknowledged the limitations of the retrospective study, noting that propensity score adjustment and matching accounts for measured confounders. “It obviously cannot account for any unmeasured confounders,” she said.

Dr. Hu reported funding from the Agency for Healthcare Research and Quality related to her position. She had no disclosures related to her presentation.

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