Should We Be Aiming For A “Stent-first Strategy” in the Management of Malignant Biliary Obstruction? A Retrospective Single-Center Analysis

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Background Percutaneous transhepatic cholangiography (PTC) is essential when endoscopic retrograde cholangiopancreatography (ERCP) fails or is contraindicated. Despite emerging evidence favoring primary stenting, data directly comparing it with the traditional two-staged drainage approach remain scarce. Purpose To evaluate the efficacy, complication rates, and reintervention burden of initial stent placement versus drainage. Material and Methods A retrospective single-center analysis of 96 patients undergoing PTC (2021–2024) was conducted; 95 received intervention (primary stent n = 30, drain n = 65). Outcomes (bilirubin kinetics, clinical success, complications, reinterventions) were compared using Welch's t -test, chi-square test, or Fisher's exact test, with multivariable adjustment for baseline differences. Results Malignant obstruction accounted for 96.8% of cases; technical success was 97.9% (CIRSE standards). Bilirubin reduction was greater with stents (45.7% vs. 35.5%; mean difference 10.2 percentage points, 95% confidence interval = 0.3–20.0; P = 0.043), attenuated after adjustment ( β = 9.8 pp; P = 0.093). Complications, all reinterventions, and combined adverse events were lower with stents (23.3% vs. 55.4%, 16.7% vs. 73.8%, and 30.0% vs. 86.2%; all P ≤0.004); adjusted analyses confirmed independently reduced odds (adjusted odds ratio = 0.26, 0.08, and 0.07, respectively). Clinical success trended higher with stents (46.7% vs. 38.5%) but was not statistically significant. Overall, 30-day mortality was 17.7% with 2% procedure-related. Median post-intervention survival was 101 days. Conclusion In this retrospective single-center cohort, a stent-first approach was associated with greater bilirubin reduction and fewer complications and reinterventions than drainage-first, without compromising technical success or survival. Findings are hypothesis-generating and require prospective multicenter validation.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.