Palliative treatment in extrahepatic biliary malignancies: A multi-institutional cohort.

Abstract

456 Background: Extrahepatic biliary malignancies (EBM) are often first diagnosed at advanced stages when the disease is no longer surgically resectable. While palliative resection may provide a more definitive solution for patients with jaundice, it also carries a higher risk of complications than endoscopic or percutaneous drainage. Herein, we analysed patients undergoing both methods of palliation to better delineate these risks. Methods: 172 patients who underwent palliative treatment for EBM between 2000 and 2014 were identified from 10 major hepato-biliary centers participating in the EBM Consortium. Clinicopathologic, operative and outcome data were collected and analyzed. We used propensity score matching to correct for confounding by indication. Results: 113 patients underwent surgery with palliative resection of their tumor (65.7%), while 59 underwent diagnostic surgery, but were treated with percutaneous or endoscopic biliary drainage instead of resection (34.3%). Patients who were not resected were more frequently jaundiced preoperatively (p = 0.001), and were more likely to undergo repeat drainage procedures (p < 0.001). After matching for functional status, age, and clinical jaundice, patients who underwent resection had significantly more complications (55.6% vs. 34.0%; p = 0.035), a higher median number of complications (1 vs. 0; p = 0.0149), a higher Clavien Dindo Grade (IIIa vs. II; p = 0.0261), a longer hospital stay (8 vs. 4 days; p < 0.001), and a notable trend towards higher perioperative mortality (10.9% vs. 1.96%; p = 0.069). Meanwhile the postoperative bilirubin level was equal among the resected (1.80 mg/dL (IQR, 0.60-8.90)) and drainage groups (2.45 (IQR 0.60-10.5))(p = 0.477), and both groups had a statistically significant drop after treatment (resection 8.30 mg/dL to 1.80 mg/dL, p < 0.001; drainage 8.4 to 2.45, p < 0.001). Conclusions: Both palliative resection and biliary drainage successfully treated EBM patients’ hyperbilirubinemia. However, in a propensity score matched group, palliative resection patients had more complications and a trend towards more perioperative mortality, urging caution in the selection of patients for these procedures.