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

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

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

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): 904-914.

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

Methods Data source: ACS NSQIP Procedure Targeted Hepatectomy 2014-2017 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

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

Predictors of PTBD Use Characteristic P-value Age 0.97 (0.95-0.99) 0.002* ASA class (ref: I-II) 0.007* III 2.38 (1.18-4.76) 0.016* IV or V 4.66 (1.83-11.88) 0.002* Hypoalbuminemia 2.43 (1.39-4.22) 0.002* Weight loss 1.59 (0.87-2.92) 0.133 Neoadjuvant chemotherapy 1.08 (0.56-2.10) 0.818 Procedure (Ref: Partial lobectomy) 0.377 Left total lobectomy 0.90 (0.36-2.21) 0.810 Right total lobectomy/trisegmentectomy 1.38 (0.72-2.65) 0.326 Biliary reconstruction 1.26 (0.60-2.66) 0.540 Histology (Ref: Cholangiocarcinoma/gallbladder 0.008* cancer) Hepatocellular carcinoma 1.36 (0.50-3.70) 0.541 Other primary hepatobiliary cancer 3.85 (1.57-9.46) 0.004* Metastatic cancer 0.89 (0.34-2.34) 0.806 *Other non-significant characteristics in model: sex, race, preoperative blood transfusion, concurrent ablation, concurrent partial resection

Postoperative Complications Unadjusted Adjusted PS Adjusted PS Matched Death or serious morbidity 1.99 (1.26-3.13)* 1.82 (1.18-2.79)* 1.79 (1.16-2.76)* 2.17 (1.16-4.09)* Overall SSI 1.78 (1.14-2.79)* 1.91 (1.18-3.11)* 1.96 (1.20-3.18)* 1.85 (0.92-3.72) Superficial SSI 2.01 (1.07-3.78)* 2.36 (1.30-4.27)* 2.64 (1.39-5. 01)* 2.51 (0.96-6.61) Deep/organ space SSI 1.34 (0.85-2.14) 1.33 (0.82-2.15) 1.37 (0.84-2.21) 1.35 (0.66-2.75) Post-hepatectomy liver failure 1.88 (1.12-3.17)* 1.59 (0.80-3.14) 1.61 (0.82-3.14) 1.54 (0.54-4.03) Bile leakage 1.73 (1.09-2.75)* 1.59 (0.99-2.54) 1.68 (1.05-2.70)* 1.33 (0.66-2.71) Prolonged length of stay 1.81 (1.05-3.12)* 1.49 (0.72-3.06) 1.55 (0.72-3.31) 1.30 (0.48-3.55) *Non-significant postoperative outcomes: sepsis or septic shock, reoperation, invasive intervention, readmission

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

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