Early chemotherapy after endoscopic retrograde cholangiopancreatography and survival in advanced pancreatic cancer with biliary obstruction

doi:10.3748/wjg.122338

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Publication Name

World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Retrospective Cohort Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Jan 14, 2027; 33(2): 122338
Published online Jan 14, 2027. doi: 10.3748/wjg.122338

Early chemotherapy after endoscopic retrograde cholangiopancreatography and survival in advanced pancreatic cancer with biliary obstruction

Yun-Xiu Liao, Meng-Yu Cao, Yu-Fan Chen, Qing Yang, Shi-Yong Lin, Yin Li, Jun Weng, Xin-Xin Huang, Xiao-Yan Gao, Guo-Bao Wang, Jian-Jun Li, Hong-Bo Shan

Yun-Xiu Liao, Meng-Yu Cao, Yu-Fan Chen, Qing Yang, Shi-Yong Lin, Yin Li, Jun Weng, Xin-Xin Huang, Xiao-Yan Gao, Guo-Bao Wang, Jian-Jun Li, Hong-Bo Shan, Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China

Co-corresponding authors: Jian-Jun Li and Hong-Bo Shan.

Author contributions: Liao YX contributed to the conception and design of the study, performed the statistical analysis, interpreted the data and drafted the manuscript; Liao YX, Cao MY, and Chen YF participated in data acquisition and data curation; Cao MY, Chen YF and Yang Q accessed and verified the underlying study data; Li JJ and Shan HB supervised the study and provided methodological oversight as co-corresponding authors; Liao YX, Cao MY, Chen YF, Yang Q, Lin SY, Li Y, Weng J, Huang XX, Gao XY, Wang GB, Li JJ, and Shan HB critically reviewed the manuscript for important intellectual content, approved the final version, and accepted responsibility for the decision to submit the manuscript for publication.

AI contribution statement: ChatGPT (OpenAI) was used during manuscript revision to assist with English language polishing and formatting consistency. It was not used for data generation, statistical analysis, or scientific interpretation. The authors independently reviewed and approved all content and take full responsibility for the manuscript.

Supported by Guangzhou Clinical Specialty Technology Construction Project, No. 2026P-TS016.

Institutional review board statement: This study was reviewed and approved by the Institutional Review Board of Sun Yat-Sen University Cancer Center (approval No. B2025-744-01).

Informed consent statement: The requirement for informed consent was waived by the ethics committee because of the retrospective nature of the study.

Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.

STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.

Data sharing statement: No additional data are available. The datasets generated and analyzed during the current study are not publicly available because of institutional privacy and ethical restrictions.

Corresponding author: Hong-Bo Shan, Department of Endoscopy, Sun Yat-sen University Cancer Center, No. 651 Dongfengdong Street, Yuexiu District, Guangzhou 510060, Guangdong Province, China. shanhb@sysucc.org.cn

Received: April 16, 2026
Revised: May 20, 2026
Accepted: June 22, 2026
Published online: January 14, 2027
Processing time: 208 Days and 21 Hours

Abstract

BACKGROUND

Advanced pancreatic ductal adenocarcinoma is commonly complicated by malignant distal biliary obstruction, for which endoscopic retrograde cholangiopancreatography (ERCP)-guided drainage is used to relieve jaundice and restore treatment eligibility. However, its clinical value may depend on whether drainage enables timely transition to systemic chemotherapy. Evidence evaluating early chemotherapy after ERCP while accounting for time-related bias remains limited.

AIM

To evaluate whether chemotherapy initiation within 30 days after ERCP is associated with landmark overall survival (OS).

METHODS

This single-center retrospective cohort study included patients with unresectable locally advanced or metastatic pancreatic ductal adenocarcinoma and malignant distal biliary obstruction who underwent index ERCP-guided drainage from 2016 to 2025. A 30-day landmark design was used. Inverse probability of treatment weighting-weighted Kaplan-Meier and Cox models evaluated landmark OS. Firth logistic regression and competing-risk analyses explored factors associated with chemotherapy initiation within 30 days.

RESULTS

Among 63 ERCP patients, 61 entered the landmark cohort; 36 initiated chemotherapy within 30 days and 25 did not. Chemotherapy initiation within 30 days was associated with better landmark OS (hazard ratio = 0.36, 95%CI: 0.20-0.67, P = 0.001), with a 365-day restricted mean survival time difference of 120.4 days. Higher baseline bilirubin was associated with lower odds of chemotherapy initiation (odds ratio = 0.29, 95%CI: 0.09-0.74, P = 0.008). The 30-day cumulative incidence of chemotherapy initiation was 72.7% in the low-bilirubin group and 41.4% in the high-bilirubin group; persistently high bilirubin at baseline and day 7 identified the lowest-accessibility subgroup.

CONCLUSION

Early chemotherapy after ERCP was associated with better landmark survival. Baseline and early bilirubin dynamics may help identify patients at risk of bridging failure.

Keywords: Pancreatic ductal adenocarcinoma; Malignant distal biliary obstruction; Endoscopic retrograde cholangiopancreatography; Biliary drainage; Chemotherapy accessibility; Landmark analysis; Competing risk; Overall survival

Core Tip: This study reframed endoscopic biliary drainage in advanced pancreatic cancer as a bridge-to-chemotherapy intervention rather than a purely technical procedure. Using a 30-day landmark design with inverse probability weighting, early chemotherapy after drainage was associated with better survival. Baseline total bilirubin and early post-drainage bilirubin trajectory identified patients less likely to enter systemic therapy, supporting a pathway-oriented view of biliary drainage and early risk stratification after endoscopic intervention.