Abstract
Background and Aims
Nonsurgical management of malignant biliary obstruction (MBO) in pancreatic cancer (PC) and cholangiocarcinoma (CCA) includes endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided biliary drainage (EUS-BD), and percutaneous transhepatic biliary drainage (PTBD). EUS-BD is increasingly utilized. However, comparative effectiveness studies remain limited. This study evaluates in-hospital adverse events following ERCP, EUS-BD, or PTBD for MBO.
Methods
The National Inpatient Sample from 2005-2020 was queried to identify adult patients with PC or CCA hospitalized with MBO. Patients were stratified by initial therapeutic approach: ERCP, EUS-BD, or PTBD. Hierarchical logistic regression evaluated adverse events (AEs: bile leak, perforation, infection, bleeding). Sensitivity analyses were performed for intrahepatic CCA (iCCA), hilar/distal CCA (dCCA), and PC. Secondary outcomes (in-hospital mortality, discharge other than home [DOTH], length of stay [LOS]) were assessed using logistic and negative binomial regression; results were reported as odds ratios (OR) or coefficients (coef.).
Results
Among 196,617 admissions, 68.0% underwent ERCP, 24.7% PTBD, and 7.3% EUS-BD. Utilization of ERCP and EUS-BD increased (+0.54% and +0.45%), while PTBD declined (-0.35%; p<0.001). Compared to ERCP, EUS-BD(OR: 1.83; p<0.001) and PTBD (OR: 2.10; p<0.001) had higher odds of AEs. In iCCA, EUS-BD showed comparable odds (p=0.13), while PTBD had higher odds (OR: 1.72; p=0.002). In dCCA, EUS-BD (p=0.25) and PTBD (p=0.075) showed no significant difference. For PC, EUS-BD(OR: 1.78; p=0.002) and PTBD (OR: 2.19; p<0.001) had higher AE risk. PTBD also showed higher mortality (OR: 2.03; p<0.001), DOTH(OR: 1.52; p<0.001), and longer LOS (coef.: 0.35; p<0.001). EUS-BD showed similar mortality (p=0.88), DOTH (p=0.60), and LOS (p=0.65).
Conclusion
In this nationwide, real-world analysis, EUS-BD and PTBD were associated with higher odds of composite AEs compared with ERCP; however, these associations varied by tumor subtype. These findings should be interpreted in the context of the retrospective study design and highlight the importance of considering obstruction site, tumor type, and patient-specific factors with a multidisciplinary approach involving gastroenterology and interventional radiology.