3:00 PM Abstract No. 160 Obstructive cholangiocarcinoma: hilar location as an indication for initial percutaneous management

Abstract

The best initial therapy for hilar biliary obstruction is unclear: endoscopic retrograde cholangio-pancreatography (ERCP) is utilized by many clinicians, despite evidence suggesting that percutaneous transhepatic biliary drainage (PTBD) may be more appropriate in this setting [1]. The purpose of this study is to identify the influence of cholangiocarcinoma location on therapy outcomes. Records of 122 patients with newly diagnosed cholangiocarcinoma requiring biliary decompression from 2007 to 2016 were retrospectively reviewed. Preprocedural MRI was used to classify tumor location for 84% of patients. When this was not available, fluoroscopic procedural images were used. Hilar cholangiocarcinoma (Klatskin tumor) was present in 74 patients, and 41 had tumor involving the common hepatic and/or common bile ducts but not the hilum. PTBD was the initial therapy for 57 patients, and 65 were initially treated by ERCP. Therapeutic success was defined as resolution of hyperbilirubinemia to below 2.5 mg/dL, a level at which systemic chemotherapy can be safely administered. Of the group receiving initial ERCP treatment, 18/33 (55%) patients with hilar cholangiocarcinoma required conversion to PTBD within 30 days, compared to 4/28 (14%) with cholangiocarcinoma of the common hepatic or common bile ducts. Patients with hilar tumors are therefore over three times more likely to fail endoscopic management (p = 0.001). Immediately apparent technical failure of ERCP stent placement occurred in 9/33 (27%) patients with hilar tumors. The ERCP and PTBD treatment groups had average pretreatment serum total bilirubin concentrations of 17.5 and 17.4 mg/dl, respectively. In both treatment groups, half of the patients reached therapeutic success within the period of available follow-up data. The PTBD group had a shorter mean time to therapeutic success of 33 days vs. 41 days for the ERCP group. Hilar location of cholangiocarcinoma is a strong predictor of failure of endoscopic management. PTBD as the first-line therapy for these patients could minimize the number of procedures performed and the associated complication risks. MRI is useful to determine which treatment best suits a patient.