Background: Malignant obstructive jaundice is associated with a poor prognosis. Patients can undergo percutaneous transhepatic biliary drainage (PTBD), but the impact it has on quality of life is not well understood.
Objective: To assess the potential impact of PTBD on quality of life in patients with obstructive jaundice from advanced malignancy using surrogate markers including complications, hospital length of stay, readmission, reintervention, and mortality.
Methods: A retrospective analysis of a single-centre cohort of all patients with advanced solid organ malignancy undergoing PTBD between April 2020 and February 2022. Data was collected from electronic medical records.
Results: Among the sixteen patients, abdominal pain and cholangitis were observed in 62.5% and 37.5% patients, respectively. Peritonitis, biliary leak, perihepatic abscess, and haemobilia occurred in individual cases. The median hospital length of stay post PTBD was nine days. The 30-day readmission rate for PTBD-related complications was 31.3% with a median of three total readmissions per patient. The 30-day reintervention rate was 62.5%. The 30-day all-cause mortality was 25% (95% CI:8.9-53.3), which included one procedure-related death.
Conclusions: Quality of life in patients with obstructive jaundice from advanced solid organ malignancy undergoing PTBD can be adversely impacted due to the high risk of complications, reintervention, hospitalisation, and mortality. Thorough patient assessments are crucial in selecting appropriate candidates for PTBD.
Percutaneous Transhepatic Biliary Drainage; Malignant Biliary Obstruction; Obstructive Jaundice; Quality of Life; Cancer
Obstructive jaundice is an ominous complication of solid organ cancer and carries a poor prognosis [1]. Most cases of malignant obstructive jaundice are too advanced for curative surgical management [2], so select patients can undergo percutaneous transhepatic biliary drainage (PTBD) instead. This is a well-recognised palliative procedure that can alleviate symptomatic hyperbilirubinemia and bridge patients to systemic anticancer treatment, which can improve survival [3]. However, this procedure is associated with morbidity and mortality [4], which may conflict with the goals of optimising quality of life. The impact of PTBD on a patient’s quality of life, which is often a paramount consideration in this cohort of patients, is unclear. This study outlines that in patients with advanced solid organ malignancy and obstructive jaundice, PTBD can carry a considerable risk of procedural complications, reintervention, and increased hospitalisation, all of which can undermine quality of life. These factors are not well described in the literature. These factors are possibly underestimated given the paucity in the medical studies and there is limited data from small studies which have examined readmission rates and length of stay after PTBD for malignant obstructive jaundice. Further exploration in these factors is crucial due to their potential impact on a patient’s quality of life and to increase clinician’s awareness of these issues which are often unrecognised. Careful individualised patient assessment to determine suitability of PTBD and ensuring that the procedure aligns with the goals of care is crucial. Moreover, considering of a conservative palliative approach should be discussed with patients deemed unsuitable for PTBD.
This is a retrospective cohort analysis of patients with solid organ malignancies and obstructive jaundice, who had undergone PTBD between April 2020 and February 2022 at a tertiary teaching hospital. Data was collected and analysed from the electronic medical records including baseline patient characteristics, post-procedural complications, length of hospital stay post PTBD, 30-day readmission rate, total number of readmissions, 30-day reintervention rate, and 30-day mortality.
There were sixteen patients identified and 56.3% were male, with a median age of 70 (range: 51-86) years. All patients had unresectable cancer, and 81.3% had metastatic disease. Among them, abdominal pain, cholangitis, and stent dysfunction were observed in 62.5%, 37.5%, and 25% of patients, respectively. Additionally, individual cases of peritonitis, biliary leak, perihepatic abscess, and haemobilia were also observed. The median hospital length of stay post PTBD was 9 (range: 3-19) days. The 30-day reintervention rate was 62.5% and included repeat PTBD or endoscopic retrograde cholangiopancreatography. The 30-day readmission rate for PTBD-related complications was 31.3%. There was a median of three total readmissions per patient for PTBD-related complications. The 30-day all-cause mortality was 25% (95% CI:8.9-53.3), which included one procedure-related death.
There are several limitations of the presented study. This is a retrospective analysis of a small sample size with heterogeneity amongst patients and relying on detailed data from the electronic medical records. However, this study captured all appropriate patients within the data collection timeframe and the generatability is heightened by examining a particular cohort of patients with advanced solid organ malignancy. Despite these limitations, the study explores a topic that is poorly understood. It serves as a reminder of the palpable morbidity and mortality of PTBD and to ensure a comprehensive assessment is performed to select appropriate candidates for the procedure.
This study used objective data, including complications, length of hospital stays, reintervention, and readmission data as surrogates for quality of life. Importantly, these factors have not been well described. Currently, there is limited and conflicting data in the medical literature about the impact of PTBD on quality of life, which has been analysed subjectively using questionnaires [5-7].
In this study, all patients had at least one complication with abdominal pain, cholangitis, and stent dysfunction being the most prominent. Post-PTBD complications such as sepsis, cholangitis, and stent dysfunction have been reported to be up to 30% of patients [8]. Progression of disease may be a confounding factor contributing to these complications, especially in patients not receiving palliative anticancer therapy. Equally, comorbidities, cancer-related pain, and psychosocial issues may require multidisciplinary management and may prolong admission.
Two notable studies have examined readmission data post-PTBD. One reported a 30-day readmission rate of 20.8% and a median length of stay of nine days [9]. Another study reported a mean length of stay of 16.6 days post-PTBD [10]. These are comparable figures in this analysis whereby the 30-day readmission rate was 31.3% and a median length of hospital stay of nine days. Furthermore, this analysis identified a median of three readmissions for PTBD-related complications, which serves as a reminder that complications may be subacute and require hospital admission after discharge. The complex dynamics of these factors can all influence adversely impact quality of life.
Repeat biliary drainage procedures are common, and one study describes that up to 30% of patients will have recurrent obstructive jaundice at some stage of their illness requiring reintervention [8]. This cohort of patients comprised of cases with advanced malignancy and the majority have unresectable metastatic disease, so it is not overly surprising that over 60% of patients required reintervention within 30 days.
Mortality rates were high in this study, with death being observed in 25% of patients within 30 days. However, this is similar to the current literature with a large retrospective cohort study reporting 30-day mortality rate of 23.1% and age being the most significant factor in the multivariable analysis4, noting that this study comprised an elderly cohort of patients with a median age of 70 years.
In this cohort of patients with obstructive jaundice from advanced solid organ malignancy, PTBD carried a high risk of complications, reintervention, and hospitalisation, which can all negatively impact quality of life. Importantly, there is high early mortality in this population. Although these results warrant larger prospective validation, this study emphasises that conducting thorough individualised assessments are crucial in selecting suitable candidates for PTBD, and ensuring it aligns with the goals of care. In those deemed unsuitable for PTBD, a conservative palliative approach should be considered.
LV is the primary author and guarantor of this article. SC had substantial contribution to study design, analysis, interpretation and drafting of the manuscript. DE had substantial contribution to data interpretation. All authors approved the final version of the manuscript.
Conflict of Interests
None to report.
Funding
None to report.
Ethics
Ethics was approval by GCHHS Research Governance Authorization. (HREC reference: LNR/2022/QGC/8537)
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