Endoscopic biliary stenting combined with nasobiliary drainage in hilar malignant biliary obstruction

Background Endoscopic drainage for hilar malignant biliary obstruction (HMBO) has no consensus regarding the optimal strategy. In this retrospective study, we compared transpapillary plastic stent (PS) plus endoscopic nasobiliary drainage (ENBD) with PSs alone for HMBO, and evaluated the risk factors on cholangitis in PS plus ENBD group. Methods We recruited 175 consecutive patients (Bismuth type II-IV) who underwent either PS plus ENBD or PSs alone. To overcome selection bias, we performed 1:1 propensity score matching. Our primary endpoint was successful drainage. Univariate analyses were used to assess risk factors. Results After propensity score matching, each group comprised 74 patients, with no significant differences in any baseline characteristics. The successful drainage rate was 77.0% in the PS plus ENBD group and 68.9% in the PSs alone group, with no statistical difference ( P  = 0.267). Cholangitis (23.0% vs. 10.8%, P  = 0.048) and overall adverse events (AEs) (29.7% vs. 12.2%, P  = 0.009) rates were statistically higher in PSs alone group than that in PS plus ENBD group. There were no statistical differences in the biliary patency, reintervention and survival time between the two groups. The median survival time in PS plus ENBD and PSs alone groups was 102 and 81 days, respectively ( P  = 0.078). We converted external drainage to internal drainage by snipping the nasobiliary catheter with scissor forceps in 19 patients. Initial drainage was more frequent among cholangitis patients (100.0% vs. 59.3%, P  = 0.011). The median drainage volume in cholangitis and non-cholangitis groups was 85 and 250 mL, respectively ( P  = 0.021). Conclusions Endoscopic biliary stenting combined with ENBD and subsequent nasobiliary catheter snipping were safe and effective for HMBO. PS plus ENBD decreased the rates of cholangitis and overall AEs. Initial drainage and drainage volume were associated with cholangitis in PS plus ENBD group.