Outcomes following biliary decompression interventions for jaundiced patients with malignant intrahepatic obstruction from metastatic cancer.
TL;DR
Despite high technical success, only 38% achieved bilirubin ≤2 mg/dL after IBDI and median survival was 7 weeks, highlighting the importance of careful patient selection and earlier goals-of-care discussions.
Abstract
293 Background: Hyperbilirubinemia due to malignant intrahepatic biliary obstruction frequently limits eligibility for systemic therapy. Intrahepatic biliary drainage interventions (IBDI), including endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD), are commonly performed to reduce bilirubin levels and facilitate treatment. However, data on their clinical effectiveness remain limited. We aimed to share updated data of our study on effectiveness and outcomes of IBDI in patients with malignant intrahepatic biliary obstruction and jaundice. Methods: We conducted a single-center retrospective cohort study of adults with stage IV malignancy involving the liver causing intrahepatic biliary obstruction at or above level of hilum and bilirubin >1.4 mg/dL who underwent IBDI between January 2023 and February 2025. Primary endpoint was achievement of bilirubin ≤2 mg/dL after IBDI. Secondary endpoints included receipt of 5-FU-, irinotecan-, or gemcitabine-based chemotherapy and overall survival. Time-varying Cox models evaluated the association between chemotherapy and survival. Results: Among 361 screened patients, 150 met inclusion criteria. Median survival after IBDI was 7 weeks. 57 patients achieved bilirubin ≤2 mg/dL (clinical success 38%). 43 patients (29%) received 5-FU-, irinotecan-, or gemcitabine-based chemotherapy, including 15 treated despite bilirubin >2 mg/dL. Among 27 patients achieving bilirubin ≤2 mg/dL but not receiving 5-FU, irinotecan, or gemcitabine, 13 received alternative systemic therapy. After adjustment for age, sex, baseline bilirubin, and extent of hepatic involvement, receipt of 5-FU-, irinotecan-, or gemcitabine-based chemotherapy was associated with lower mortality risk (HR 0.56, 95% CI 0.34–0.93; p=0.025). Goals-of-care discussions before IBDI occurred in only 9% of patients. Conclusions: Despite high technical success, only 38% achieved bilirubin ≤2 mg/dL after IBDI and median survival was 7 weeks. These findings highlight the importance of careful patient selection and earlier goals-of-care discussions. Comparison of pertinent characteristics between those who received 5-FU-, irinotecan-, or gemcitabine-based chemotherapy following IBDI vs. those who did not. Variable Overall(n = 150) Not treated(n = 107) Treated(n = 43) p-value Age, Mean (SD) 60.4 (11.6) 62.6 (11.3) 55.0 (10.6) <0.001 Total bilirubin prior to intervention, Mean (SD) 9.6 (5.7) 10.1 (6.0) 8.3 (4.8) 0.059 Primary cancer, n (%) Biliary 30 (20.0%) 19 (17.8%) 11 (25.6%) 0.027 Colorectal 44 (29.3%) 26 (24.3%) 18 (41.9%) Index Biliary Intervention ERCP 133 (89.3%) 98 (92.5%) 35 (81.4%) 0.076 PTBD 16 (10.7%) 8 (7.5%) 8 (18.6%) Admitted to hospice 98 (65.3%) 78 (72.9%) 20 (46.5%) 0.004 Death 132 (88.0%) 96 (89.7%) 36 (83.7%) 0.404