E0016 - Outcomes of Percutaneous vs Endoscopic Biliary Drainage in Malignant Hilar Obstruction: Analysis of a Large Electronic Health Record Dataset

Wilfredo Pagani, MD¹, B. Joseph Elmunzer, MD, MSc², Zachary L. Smith, DO^1
1Medical College of Wisconsin, Milwaukee, WI; ²Medical University of South Carolina, Charleston, SC

Introduction: Most patients with malignant hilar obstruction (MHO) will require biliary drainage with percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde cholangiopancreatography (ERCP). Two recent randomized control trials (RCTs) attempted to directly compare these modalities; however, both were terminated prematurely. Post-hoc analyses for both studies revealed higher short-term all-cause mortality in the PTBD group, only one of which reached statistical significance with a wide confidence interval. It is important to better define this mortality signal to further the understanding of an area in which there remains clinical equipoise regarding the optimal biliary drainage strategy. This study aimed to evaluate 90-day all-cause mortality and other outcomes in patients undergoing ERCP and PTBD for MHO.

Methods: Data from TriNetX, an electronic health record-derived national dataset was used. Current procedural terminology (CPT) and international classification of disease (ICD) codes were used to establish a cohort of adult patients with MHO that underwent ERCP or PTBD as initial biliary drainage strategy from 2010-2020. Patients who underwent ERCP or PTBD in the preceding year before diagnosis and index drainage procedure were excluded. Propensity matching was performed based on age, sex, race, ethnicity, serum bilirubin, carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 at the time of the index drainage procedure. After matching, univariate and Kaplan-Meier analyses were performed.

Results: A total of 4,061 patients were identified. After matching, both cohorts contained 587 patients. All covariates were well-matched aside from higher bilirubin and CA 19-9 levels in the PTBD group. All cause 90-day mortality was lower for the ERCP cohort compared with the PTBD cohort (17.2% vs 26.7%, OR 0.6, 95% CI 0.43-0.75). At 6 months, there was no significant difference between the cohorts in rates of curative surgical resection or liver transplant (3.4% vs 5.1%, OR 0.72, 95% CI 0.41-1.25) or chemotherapy utilization (19.6% vs 16.7%, OR 1.2, 95% CI 0.87-1.70) between the PTBD and ERCP groups, respectively.

Discussion: Patients undergoing ERCP for MHO have significantly lower 90-day all-cause mortality compared with those undergoing PTBD. While the possibility of selection bias due to unidentified confounding variables exists, these findings are consistent with those from prematurely terminated RCTs and may help inform the design of future RCTs in this patient population.




Disclosures:


Wilfredo Pagani, MD¹, B. Joseph Elmunzer, MD, MSc², Zachary L. Smith, DO¹. E0016 - Outcomes of Percutaneous vs Endoscopic Biliary Drainage in Malignant Hilar Obstruction: Analysis of a Large Electronic Health Record Dataset, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.