Influence of effective liver drainage volume on overall survival in patients with malignant hilar biliary obstruction: a multicenter study / 中华消化内镜杂志

ABSTRACT

Objective:To investigate the influence of liver drainage volume on overall survival time in patients with unresectable malignant hilar bile duct obstruction.Methods:Data of 633 patients with unresectable malignant hilar bile duct obstruction (BismuthⅡ-Ⅳ) who underwent endoscopic stent drainage in 3 endoscopy centers from January 2002 to May 2019 were retrospectively analyzed. Main observation indicators included clinical success rate, stent patency, overall survival, the effective liver drainage volume, and complication incidence.Results:The clinical success rates of patients with liver drainage volume <30%, 30%-50%, and >50% were 56.8% (25/44), 77.3% (201/260) and 84.2% (277/329) respectively. The incidences of early cholangitis were 31.8% (14/44), 18.8% (49/260) and 16.1% (53/329). The median stent patency time was 4.5 (95% CI 1.8-7.2) months, 5.6 (95% CI 5.0-6.2) months and 6.6 (95% CI 5.2-8.0) months. The overall survival time was 2.4 (95% CI 1.8-3.0) months, 4.0 (95% CI 3.4-4.6) months and 4.9 (95% CI4.4-5.4) months, respectively. The clinical success rate ( χ 2=8.28, P=0.012), median stent patency period ( χ 2=18.87, P=0.015) and overall survival time ( χ 2=6.93, P=0.024) of 30%-50% liver drainage volume group were significantly higher than those of <30% group. Further multivariate cox regression analysis showed that the disease type (hepatocellular carcinoma VS hilar cholangiocarcinoma HR=1.50, 95% CI1.18-1.91, P=0.001; gallbladder carcinoma VS hilar cholangiocarcinoma HR=1.45, 95% CI1.14-1.85, P=0.002; metastatic cholangiocarcinoma VS hilar cholangiocarcinoma HR=1.48, 95% CI1.08-2.04, P=0.015), bilirubin level >200 μmol/L ( HR=1.35, 95% CI1.14-1.60, P<0.001),metal stents ( HR=0.67, 95% CI0.56-0.79, P<0.001), liver drainage volume (volume 30%-50% VS <30% HR=0.64, 95% CI 0.45-0.90, P=0.010; volume>50% VS <30% HR=0.58, 95% CI0.41-0.81, P=0.002) and anti-tumor therapy ( HR=0.51, 95% CI0.42-0.61, P<0.001) were independent predictors for overall survival time of patients with unresectable malignant hilar bile duct obstruction. Conclusion:When endoscopic stent drainage is performed for patients with unresectable malignant hilar bile duct obstruction, at least 30% liver volume is required for better overall survival. In addition, the use of metal stent drainage and anti-tumor therapy may increase survival benefits.