Optimal Stenting Strategy During Chemotherapy: Impact of Time to First Reintervention on Survival in Malignant Hilar Biliary Obstruction.
Time to first reintervention is a significant prognostic factor in patients with malignant hilar biliary obstruction undergoing chemotherapy, particularly with stenting above the sphincter of Oddi.
Where it sits
this study against the rest of the glutathione (gsh) corpusSummary and findings
The study evaluated the prognostic value of time to first reintervention (TTFR) in 81 patients with malignant hilar biliary obstruction (MHBO) who underwent biliary stenting followed by chemotherapy. The median TTFR was 167 days, and it was correlated with overall survival. Stenting above the sphincter of Oddi was identified as an independent factor affecting TTFR.
Abstract
Objectives Advances in chemotherapy have increased survival in biliary tract cancer patients, and reports of the effectiveness of neoadjuvant therapy are emerging. Accordingly, developing optimal drainage strategies under chemotherapy is important. We aimed to clarify suitable drainage methods and assess the prognostic value of the time to first reintervention (TTFR) following chemotherapy induction. Methods We retrospectively analyzed 81 patients with malignant hilar biliary obstruction (MHBO) who underwent biliary stenting followed by chemotherapy between April 2012 and October 2023. TTFR following chemotherapy induction and drainage- and survival-related factors were evaluated. Results The median follow-up, survival, and TTFR were 425, 479, and 167 days, respectively. TTFR was correlated with overall survival (r = 0.60, p < 0.01). Univariable analyses identified prechemotherapy cholangitis and stenting above the sphincter of Oddi (SO) as factors associated with shorter TTFR, whereas multivariable analysis revealed stenting above the SO as the only independent factor (hazard ratio [HR] 0.44, p = 0.01). Among 52 non-endoscopic sphincterotomy (EST) patients, prechemotherapy cholangitis (HR 2.05, p = 0.04), stenting above the SO (HR 0.47, p = 0.04), and multiple drainage segments (HR 0.42, p = 0.04) influenced TTFR in univariable analyses. No significant factor was detected among 28 patients undergoing EST. The TTFR was comparable between above- and across-SO placement groups up to 2 months, but superior in the above-SO group at 6 months (69%-73% vs. 27%-42%). Conclusions TTFR following chemotherapy induction is a prognostic factor in MHBO patients. Stenting above the SO may prolong TTFR, particularly in those without prior EST or expected to continue chemotherapy beyond 2 months. Trial Registration: N/A.
Background
This study addresses the impact of drainage strategies during chemotherapy in patients with malignant hilar biliary obstruction (MHBO). Prior research has indicated that chemotherapy can improve survival in biliary tract cancer, but optimal drainage methods during treatment remain unclear. Understanding the prognostic value of time to first reintervention (TTFR) could enhance treatment strategies and patient outcomes.
Methods
The study retrospectively analyzed 81 patients with MHBO who underwent biliary stenting followed by chemotherapy from April 2012 to October 2023. The primary outcome was TTFR following chemotherapy induction, with secondary evaluations of survival-related factors. The analysis included univariable and multivariable assessments.
Results
The median TTFR was 167 days, and it was significantly correlated with overall survival (r = 0.60, p < 0.01). Stenting above the sphincter of Oddi was the only independent factor affecting TTFR in multivariable analysis (HR 0.44, p = 0.01). In patients without endoscopic sphincterotomy, prechemotherapy cholangitis (HR 2.05, p = 0.04) and multiple drainage segments (HR 0.42, p = 0.04) were also significant.
Interpretation
The findings suggest that TTFR is a relevant prognostic factor in MHBO patients undergoing chemotherapy, particularly with stenting above the sphincter of Oddi. While the correlation with overall survival is statistically significant, the clinical significance may be limited by the small sample size and retrospective nature of the study. The lack of significant findings in the endoscopic sphincterotomy group indicates potential confounding factors that warrant further investigation.
Key findings
- Median follow-up of 425 days, survival of 479 days, and TTFR of 167 days.
- TTFR correlated with overall survival (r = 0.60, p < 0.01).
- Stenting above the sphincter of Oddi had a hazard ratio (HR) of 0.44, p = 0.01.
- Prechemotherapy cholangitis had a HR of 2.05, p = 0.04.
- TTFR was 69%-73% in the above-SO group at 6 months compared to 27%-42% in the across-SO group.
Limitations
- Retrospective analysis with small sample size (n=81).
- No randomization or control group.
- No significant factors detected among patients undergoing endoscopic sphincterotomy.
- Findings may not be generalizable beyond the study population.