Cholangiocarcinoma Clinical Trial
Official title:
A Multicenter Randomized Trial of Percutaneous Transhepatic Biliary Drainage vs. Endoscopic Retrograde Cholangiography for Decompression of Suspected Malignant Biliary Hilar Obstruction - the INTERCPT Trial
The optimal approach to the drainage of malignant obstruction at the biliary hilum remains uncertain. This is a randomized comparative effectiveness study of percutaneous transhepatic biliary drainage (PTBD) vs. endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction.
Both percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde
cholangiography (ERC) are accepted approaches in the management of patients with malignant
obstruction at the biliary hilum. In routine clinical practice, ERC is generally favored on
the basis of: 1) high technical and clinical success rates for other (non-hilar) indications;
2) the perceived safety of ERC relative to PTBD; 3) the perceived ability to perform more
comprehensive tissue sampling at the time of ERC compared to PTBD; 4) the avoidance of
external tubes which are often needed for PTBD; and 5) because patients with suspected
malignant hilar obstruction (MHO) typically present to and are managed by
gastroenterologists. However: 1) observational data suggest that PTBD is superior for
achieving complete drainage of MHO1 and some guidelines recommend the percutaneous approach
over ERC for Bismuth type 3 & 4 hilar strictures; 2) the generally quoted risks of PTBD are
based on outdated studies and may be exaggerated; and 3) endoscopic diagnosis of
indeterminate biliary strictures remains suboptimal despite the use of cholangioscopy and
multi-modal sampling.
Although many patients who undergo initial ERC require subsequent PTBD for adequate drainage,
no randomized trials comparing the two modalities for suspected MHO have been published. The
main hypothesis is that even though PTBD will be more effective than ERC for decompression of
suspected MHO, this advantage will be offset by the favorable safety profile and superior
diagnostic capability of ERC. If, however, PTBD is found to be substantially superior (by a
pre-specified margin) in terms of drainage, or if the potential advantages of ERC are not
realized, then the existing clinical approach to MHO must be reappraised. Moreover,
identifying patient and stricture characteristics that predict response to PTBD or ERC may be
important for informing clinical decision-making and guidelines.
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