Mark Schattner, MD, FASGE, AGAF, of Memorial Sloan Kettering Cancer Center, discussed endoscopic biliary drainage (EBD) in cholangiocarcinoma (CCA), specifically in hilar obstruction, emphasizing the different goals and techniques in patients with resectable versus unresectable disease. The ultimate goals for management of obstruction in patients with resectable CCA are to optimize them for surgery and avoid perioperative complications and unnecessary procedures. Debate is ongoing as to whether percutaneous (PTC) or EBD is the more appropriate technique in patients with resectable CCA requiring drainage. Although researchers have found no differences in clinical success with EBD versus PTC, a majority of patients respond inadequately to EBD and require salvage PTC. It is important to understand which patients are most likely to not do well with EBD to spare them from unnecessary procedures. A study aimed at developing and validating a prediction model to identify patients at high risk for EBD failure identified 3 risk groups based on serum bilirubin and the Bismuth-Corlette classification: low risk, moderate risk, and high risk. In this model, 7% of low-risk patients, 40% of those with moderate risk, and 62% of high-risk patients were predicted to need salvage PTC.1 The researchers concluded that, in low-risk patients, physicians can be optimistic that EBD will be successful whereas high-risk patients should be managed with PTC. Moderate-risk patients should be evaluated in terms of physician expertise and comfort level in selecting a drainage procedure.
Goals for patients with unresectable disease are to palliate symptoms, lower bilirubin to allow for chemotherapy, avoid cholangitis, minimize repeated interventions, and improve or maintain quality of life. The current approach for management of biliary obstruction in patients with unresectable disease is stent placement and/or drainage. Stent placement can present challenges in these patients, such as failure due to tumor ingrowth, tumor overgrowth, and benign tissue hypertrophy. This is further complicated by the fact that there has been no significant improvement in stent design in many years. Stent failure is a morbid complication that results in cholangitis, repeated procedures, treatment interruptions, and increased cost. Therefore, there is a need for an ablative technique that is safe, effective, and easy to deliver, and several modalities are currently under development. These include photodynamic therapy (a 2-step procedure that results in thermal burn to the biliary epithelium), radiofrequency ablation, and laser irreversible electroporation.
Peiman Habibollahi, MD, of MD Anderson Cancer Center, discussed biliary decompression and PTC drain management in patients with CCA. Indications for biliary drainage that are nonpalliative include lowering bilirubin levels to allow for chemotherapy, enabling the delivery of local treatments, and performing cholangioscopy and tissue sampling. Palliative treatment indications are to relieve pain and other symptoms, such as anorexia and pruritus. Technical success with PTC and EBD as palliation in preoperative patients has been shown to be comparable, but EBD may be associated with higher rates of infectious complications, such as pancreatitis and cholangitis.2,3 Conversely, PTC may have a higher risk of bleeding. Dr. Habibollahi acknowledged that PTC negatively affects a patient’s quality of life, so if EBD is deemed appropriate after a multidisciplinary evaluation, it is usually the favored initial approach. If EBD is not feasible or there is probability that it will not be successful, PTC may be more appropriate upfront. After a patient workup, the most important considerations for biliary drainage with PTC are the location of the tumor and site of obstruction and the ultimate goal of drainage. Intraluminal high-dose brachytherapy (HBD) through PTC allows for delivery of a high dose of radiation to the tumor while minimizing radiation to the surrounding normal liver; in addition, intraluminal HBD may improve drain patency and patient outcomes.
Natalia Shatokhin, BSN, MSM, OCN, from Memorial Sloan Kettering Cancer Center, discussed biliary complications and drain management from a nursing perspective. Nurses play an integral role in the management of biliary obstructions and are responsible for patient education regarding biliary obstruction, coordinating referrals with an interdisciplinary team, and patient monitoring and follow-up. Nurses educate patients on symptoms of biliary drain complications due to infections, tumor ingrowth/overgrowth, collection of biliary sludge, bleeding, or stent dislocation, and when the patient should contact the healthcare team. Nurses also educate patients on symptoms of biliary drain obstruction, which can include jaundice, pruritus, fatigue, low appetite, fever, chills, light-colored urine, and dark-colored stool. Because obstructions are emergent situations that need to be immediately relieved to prevent sepsis and death from ascending cholangitis, nurses are an integral part of the healthcare team and use a multidisciplinary approach to manage biliary obstructions, restore bile flow, and prevent fatal complications.
Sean P. Cleary, MD, MSc, MPH, FACS, of the Mayo Clinic, discussed palliative surgery in BTC. He described 2 patient types in which palliative surgery may be indicated: first, in patients deemed unresectable based on intraoperative findings, and second, in patients requiring elective palliation for biliary or gastrointestinal obstruction. Dr. Cleary noted that the number of palliative procedures has declined; a study assessing trends in palliative surgery for extrahepatic biliary cancer found that palliative surgeries were being performed in 16.3% of patients between 2000 and 2004 but declined to 6.6% from 2010 to 2014.4 He noted that it may still be reasonable to perform palliative procedures in patients who are unresectable, especially in patients who have responded inadequately to interventional radiologic or endoscopic strategies or patients who have altered liver anatomy. Duodenal stenting and surgical gastrojejunostomy are surgical approaches for gastrointestinal obstruction that have extremely high technical and clinical success rates. Cholecystojejunostomy is an older surgical technique that can be used to drain the biliary tract through the gallbladder and can help decompress the biliary tree if the obstruction is below the cystic duct. Surgical segment 3 bypass is also a historical procedure for surgical biliary drainage for hilar CCA that can be used in complex patients.
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