Outcomes of Salvage Percutaneous Biliary Drainage after Occlusion of Endoscopic Stents.
OBJECTIVE
To describe outcomes of patients with malignant biliary obstruction who undergo salvage percutaneous biliary drainage after occlusion of endoscopic biliary stents.


METHODS
A single-center retrospective review was performed of 47 patients (25 men, 22 women) who underwent percutaneous biliary drainage for recurrent obstruction after endoscopic stent placement between 2005 and 2015. Primary malignancies were bile duct (n = 13), colorectal (n = 11), gallbladder (n = 7), pancreas (n = 5), hepatocellular (n = 4), and other (n = 7). Indication for salvage drain placement was infection (n = 19) and jaundice or need to decrease bilirubin (n = 28). Kaplan-Meier and Cox regression methods were used for survival analysis. Logistic and multivariate regressions were employed to identify factors associated with survival.


RESULTS
Median survival after salvage biliary drain placement was 1.8 months (95% confidence interval [CI], 1.3-2.7). Elevated international normalized ratio (INR) ≥ 1.5 before drainage was associated with poorer survival after drainage (median survival 0.7 months vs 2.4 months, P < .01). Median survival was shorter in 28 patients (64%) with bilirubin ≤ 2 mg/dL (34.2 µmol/L) after drainage (1.2 months vs 5.4 months, P < .001). Left-sided drain placement, elevated bilirubin, and elevated INR correlated with decreased likelihood of achieving bilirubin ≤ 2 mg/dL (34.2 µmol/L) (odds ratio [OR] 0.13, 95% CI, 0.02-0.71, P = .02; OR 0.18, 95% CI, 0.05-0.69, P = .01; OR 0.10, 95% CI, 0.01-0.90, P = .04).


CONCLUSIONS
Survival is limited for most patients who undergo salvage percutaneous biliary drainage. Elevated bilirubin and INR before drainage portend a poor prognosis.
Division of Interventional Radiology, City of Hope National Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA91010. Electronic address: jkessler@coh.org.
Jonathan
J
Kessler
Division of Interventional Radiology, City of Hope National Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA91010.
Aram
A
Lee
Department of Radiology, Division of Biostatistic, City of Hope National Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA91010.
Paul
P
Frankel
Department of Radiology, Division of Biostatistic, City of Hope National Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA91010.
Andrew
A
Dagis
Division of Interventional Radiology, City of Hope National Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA91010.
John J
JJ
Park
Division of Gastroenterology, City of Hope National Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA91010.
James
J
Lin
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D002140:California; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D004067:Digestive System Neoplasms / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality; D004322:Drainage / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods / Q000401:mortality; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D016879:Salvage Therapy / Q000009:adverse effects / Q000401:mortality; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D015854:Up-Regulation
D015415:Biomarkers; D001663:Bilirubin