title: Combined percutaneous-endoscopic stenting of malignant biliary obstruction: results from 106 consecutive procedures and identification of factors associated with adverse outcome.
abstract: BACKGROUND
  In patients in whom attempted endoscopic stenting of malignant biliary obstruction fails, combined percutaneous-endoscopic stenting and percutaneous stenting using expandable metallic endoprostheses offer alternative approaches to biliary drainage. Despite the popularity of the percutaneous route, there is no available evidence to support its superiority over combined stenting in this patient group. The objective of this study was to present the short- and long-term results of a large series of combined percutaneous-endoscopic stenting procedures and identify factors associated with adverse outcome.
  
  
  METHODS
  Data were retrospectively collected on patients undergoing combined percutaneous-endoscopic biliary stenting for malignant biliary obstruction between January 2002 and December 2006. Short- and long-term outcomes were recorded, and pre-procedure variables correlated with adverse outcome.
  
  
  RESULTS
  Combined biliary stenting was technically successful in 102 (96.2%) of 106 patients. Procedure-associated mortality rate was 0%. In-hospital morbidity and mortality rates were 24.5% and 16.7%, respectively, with the majority of deaths resulting from biliary sepsis. Median survival was 100 days, with a 13.7% stent occlusion rate. On multivariable analysis, baseline American Society of Anaesthesiologists (ASA) grade, decreasing serum albumin and increasing leucocyte count were independently associated with in-hospital mortality following combined stenting.
  
  
  CONCLUSIONS
  Combined biliary stenting is associated with short- and long-term outcomes equal to those reported in recent series of percutaneous transhepatic stenting. Randomised control trials, including cost-effectiveness analyses, are required to further compare these techniques. Outcomes following combined stenting may be further improved by early recognition and treatment of sepsis and scrupulous management of co-morbid disease.
authors: Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK. cpn3@le.ac.uk
authors: C P
authors: CP
authors: Neal
authors: S C
authors: SC
authors: Thomasset
authors: D
authors: D
authors: Bools
authors: C D
authors: CD
authors: Sutton
authors: G
authors: G
authors: Garcea
authors: C D
authors: CD
authors: Mann
authors: Y
authors: Y
authors: Rees
authors: C
authors: C
authors: Newland
authors: R J
authors: RJ
authors: Robinson
authors: A R
authors: AR
authors: Dennison
authors: D P
authors: DP
authors: Berry
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000150:complications*; D001653:Bile Ducts, Intrahepatic; D002277:Carcinoma / Q000150:complications*; D018281:Cholangiocarcinoma / Q000150:complications*; D002779:Cholestasis / Q000209:etiology / Q000601:surgery*; D004322:Drainage; D004384:Duodenoscopy / Q000379:methods*; D005260:Female; D005706:Gallbladder Neoplasms / Q000150:complications; D017052:Hospital Mortality; D006801:Humans; D034141:Hypoalbuminemia / Q000453:epidemiology; D007964:Leukocytosis / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods* / Q000706:statistics & numerical data; D010190:Pancreatic Neoplasms / Q000150:complications*; D011183:Postoperative Complications / Q000453:epidemiology; D011379:Prognosis; D012189:Retrospective Studies; D018805:Sepsis / Q000401:mortality; D015607:Stents; D016896:Treatment Outcome