The Efficacy of ERCP and PTBD and Comparison of Survival in Unilateral Versus Bilateral Drainage in Patients With Cholangiocarcinoma: Experience From a Single Tertiary Cancer Specialty Institute

Introduction: Patients with cholangiocarcinoma who present with jaundice undergo biliary decompression via ERCP or PTBD. To determine the clinical success and complication rates of ERCP and PTBD in the management of jaundice in cholangiocarcinoma. To compare the survival of patients who undergo unilateral versus bilateral biliary drainage. Methods: The study was approved by the institutional review board. A retrospective chart review was conducted on all patients with cholangiocarcinoma who presented with jaundice between 2002 and 2012 and underwent biliary drainage via ERCP and/or PTBD using plastic and/or metal biliary stents. Results: A total of 123 patients [median age: 63 years (range: 23-88), females: 76 (62%), Caucasians: 92 (75%)] underwent ERCP (n=123) or ERCP/PTBD (n=43). The median follow-up was 12 months (1-82 months); during the follow-up 108 patients died and 5 were alive; 10 were lost to follow-up and were censored for the analysis. Technical success of ERCP, defined as ability to place a stent, was seen in 121 (98%) patients. Clinical success defined as a decrease in total bilirubin within 30 days of the procedure was seen in 86 (70%) patients who underwent an initial ERCP and in 35 (52%) who underwent subsequent ERCPs. PTBD as a salvage procedure for biliary drainage was performed in 43 patients when drainage via ERCP failed during the initial or subsequent attempts. A total of 46 patients (37%) required dilation of the strictures prior to stent placement, more commonly seen in Bismuth type 3 & 4 strictures [Bismuth type 1 (3), type 2 (8), type 3 (17) and type 4 (17)]. Biliary stenting via ERCP was done using only plastic stents (59 patients), only metal stents (23 patients), combined metal and plastic stents (35 patients) and no stenting done in 6 patients. Complications related to ERCP included stent occlusion (33, 27%), cholangitis (28, 23%), migration (25, 20%), pancreatitis (3, 2.5%), bleeding (2, 1.5%), and ampullary stenosis (1, 0.8%). Complications related to PTBD included cholangitis (9, 7.5%), bile leak (9, 7.5%), displacement of the drain (5, 4%), and bleeding (2, 1.5%). The median overall survival of patients undergoing bilateral drainage was not clinically or statistically significantly different from that of patients undergoing unilateral drainage (13 vs 12 months; p>0.1). However, cholangitis was more common in bilateral drainage (30% vs.18%). Conclusion: ERCP has a high technical success rate but modest clinical success in the treatment of jaundice in patients with cholangiocarcinoma. PTBD, with a favorable complication rate, can be used as a salvage method when ERCP fails to provide adequate biliary drainage. Bilateral drainage does not confer survival benefit over unilateral drainage.