Preoperative Biliary Drainage Among Patients With Resectable Hepatobiliary Malignancy: Does Technique Matter?

Transcription

1 Preoperative Biliary Drainage Among Patients With Resectable Hepatobiliary Malignancy: Does Technique Matter? Q. Lina Hu, MD; Jason B. Liu, MD, MS; Ryan J. Ellis, MD, MS; Jessica Y. Liu, MD, MS; Anthony D. Yang, MD, MS; Clifford Y. Ko, MD, MS, MSHS; Ryan P. Merkow, MD, MS

2 Introduction Surgical resection = only potentially curative therapy for hepatobiliary malignancies Patients often develop biliary obstruction Preoperative biliary drainage reduces risk for perioperative morbidity and mortality

3 Biliary Drainage Techniques Percutaneous Transhepatic Biliary Drainage (PTBD) Endoscopic Biliary Stenting (EBS) Figure from: Sharaiha, R. Z., et al. (2017). "Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis." Gastrointest Endosc 85(5):

4 Objectives To determine predictors of drainage technique selection (PTBD vs EBS) To evaluate the association between preoperative biliary drainage technique and postoperative outcomes

5 Methods Data source: ACS NSQIP Procedure Targeted Hepatectomy Patient selection: Hepatobiliary resection for malignancy with preoperative biliary drainage with PTBD or EBS Predictor of interest: Drainage technique Primary outcome: 30-day death or serious morbidity (DSM) Secondary outcomes: urgical site infection, bile leakage, post-hepatectomy liver failure, invasive intervention, reoperation, prolonged length of stay, readmission Statistical analysis: Predictors of PTBD use: multivariable logistic regression Associations with postoperative complications: propensity score adjusted and propensity score matched logistic regression

6 Baseline Patient Characteristics Patient cohort: 527 patients (431 EBS and 96 PTBD) EBS N=431 (81.8%) PTBD N=96 (18.2%) p-value Mean age (standard deviation) 64.1 (11.2) 61.3 (11.6) 0.029* ASA class 0.003* I or II 100 (23.2%) 11 (11.5%) III 303 (70.3%) 71 (74.0%) IV or V 28 (6.5%) 14 (14.6%) Weight loss 75 (17.4%) 29 (30.2)% 0.004* Hypoalbuminemia 164 (38.1%) 58 (60.4%) <0.001* Dialysis requirement 0 (0%) 1 (1.0%) 0.034* Ascites 0 (0%) 3 (3.1%) <0.001* *Notable non-significant characteristics evaluated: sex, race, functional status, neoadjuvant chemotherapy, surgical procedure, histology

7 Predictors of PTBD Use Characteristic P-value Age 0.97 ( ) 0.002* ASA class (ref: I-II) 0.007* III 2.38 ( ) 0.016* IV or V 4.66 ( ) 0.002* Hypoalbuminemia 2.43 ( ) 0.002* Weight loss 1.59 ( ) Neoadjuvant chemotherapy 1.08 ( ) Procedure (Ref: Partial lobectomy) Left total lobectomy 0.90 ( ) Right total lobectomy/trisegmentectomy 1.38 ( ) Biliary reconstruction 1.26 ( ) Histology (Ref: Cholangiocarcinoma/gallbladder 0.008* cancer) Hepatocellular carcinoma 1.36 ( ) Other primary hepatobiliary cancer 3.85 ( ) 0.004* Metastatic cancer 0.89 ( ) *Other non-significant characteristics in model: sex, race, preoperative blood transfusion, concurrent ablation, concurrent partial resection

8 Postoperative Complications Unadjusted Adjusted PS Adjusted PS Matched Death or serious morbidity 1.99 ( )* 1.82 ( )* 1.79 ( )* 2.17 ( )* Overall SSI 1.78 ( )* 1.91 ( )* 1.96 ( )* 1.85 ( ) Superficial SSI 2.01 ( )* 2.36 ( )* 2.64 ( )* 2.51 ( ) Deep/organ space SSI 1.34 ( ) 1.33 ( ) 1.37 ( ) 1.35 ( ) Post-hepatectomy liver failure 1.88 ( )* 1.59 ( ) 1.61 ( ) 1.54 ( ) Bile leakage 1.73 ( )* 1.59 ( ) 1.68 ( )* 1.33 ( ) Prolonged length of stay 1.81 ( )* 1.49 ( ) 1.55 ( ) 1.30 ( ) *Non-significant postoperative outcomes: sepsis or septic shock, reoperation, invasive intervention, readmission

9 Postoperative Complications Unadjusted Adjusted PS Adjusted PS Matched Death or serious morbidity 1.99 ( )* 1.82 ( )* 1.79 ( )* 2.17 ( )* Overall SSI 1.78 ( )* 1.91 ( )* 1.96 ( )* 1.85 ( ) Superficial SSI 2.01 ( )* 2.36 ( )* 2.64 ( )* 2.51 ( ) Deep/organ space SSI 1.34 ( ) 1.33 ( ) 1.37 ( ) 1.35 ( ) Post-hepatectomy liver failure 1.88 ( )* 1.59 ( ) 1.61 ( ) 1.54 ( ) Bile leakage 1.73 ( )* 1.59 ( ) 1.68 ( )* 1.33 ( ) Prolonged length of stay 1.81 ( )* 1.49 ( ) 1.55 ( ) 1.30 ( ) *Non-significant postoperative outcomes: sepsis or septic shock, reoperation, invasive intervention, readmission

10 Postoperative Complications Unadjusted Adjusted PS Adjusted PS Matched Death or serious morbidity 1.99 ( )* 1.82 ( )* 1.79 ( )* 2.17 ( )* Overall SSI 1.78 ( )* 1.91 ( )* 1.96 ( )* 1.85 ( ) Superficial SSI 2.01 ( )* 2.36 ( )* 2.64 ( )* 2.51 ( ) Deep/organ space SSI 1.34 ( ) 1.33 ( ) 1.37 ( ) 1.35 ( ) Post-hepatectomy liver failure 1.88 ( )* 1.59 ( ) 1.61 ( ) 1.54 ( ) Bile leakage 1.73 ( )* 1.59 ( ) 1.68 ( )* 1.33 ( ) Prolonged length of stay 1.81 ( )* 1.49 ( ) 1.55 ( ) 1.30 ( ) *Non-significant postoperative outcomes: sepsis or septic shock, reoperation, invasive intervention, readmission

11 Postoperative Complications Unadjusted Adjusted PS Adjusted PS Matched Death or serious morbidity 1.99 ( )* 1.82 ( )* 1.79 ( )* 2.17 ( )* Overall SSI 1.78 ( )* 1.91 ( )* 1.96 ( )* 1.85 ( ) Superficial SSI 2.01 ( )* 2.36 ( )* 2.64 ( )* 2.51 ( ) Deep/organ space SSI 1.34 ( ) 1.33 ( ) 1.37 ( ) 1.35 ( ) Post-hepatectomy liver failure 1.88 ( )* 1.59 ( ) 1.61 ( ) 1.54 ( ) Bile leakage 1.73 ( )* 1.59 ( ) 1.68 ( )* 1.33 ( ) Prolonged length of stay 1.81 ( )* 1.49 ( ) 1.55 ( ) 1.30 ( ) *Non-significant postoperative outcomes: sepsis or septic shock, reoperation, invasive intervention, readmission

12 Limitations Only hospitals participating in ACS-NSQIP Procedure-Targeted Hepatectomy program Only surgical patients Retrospective analysis with potential selection bias for procedure

13 Conclusions Patients selected for percutaneous drainage tended to have more preoperative co-morbidities Compared to endoscopic drainage, percutaneous drainage was associated with significantly increased odds of postoperative morbidity and mortality

14 Preoperative Biliary Drainage Among Patients With Resectable Hepatobiliary Malignancy: Does Technique Matter? Q. Lina Hu, MD; Jason B. Liu, MD, MS; Ryan J. Ellis, MD, MS; Jessica Y. Liu, MD, MS; Anthony D. Yang, MD, MS; Clifford Y. Ko, MD, MS, MSHS; Ryan P. Merkow, MD, MS