Cholangiocarcinoma: preoperative biliary drainage (Con)
Summary
Routine preoperative biliary drainage (PBD) may not be necessary before major liver resection in jaundiced patients with malignant hilar obstruction. Omitting PBD can be safe for selected patients, particularly those undergoing left-sided resections.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Gastroenterology
Background:
- Malignant hilar obstruction necessitates major liver resection, increasing postoperative liver failure risk due to obstructive jaundice.
- Preoperative biliary drainage (PBD) is commonly recommended but carries risks like sepsis and tumor seeding.
Purpose of the Study:
- To evaluate the safety and efficacy of omitting routine PBD in jaundiced patients undergoing major liver resection for cholangiocarcinoma.
Main Methods:
- A series of 62 patients with cholangiocarcinoma underwent major liver resection.
- 33 jaundiced patients (bilirubin 60-470 µmol/l) were operated without PBD.
- Surgical procedures included 43 extended right hepatectomies and 18 extended left hepatectomies.
Main Results:
- Overall hospital mortality was 8% (5 patients).
- Jaundiced patients without PBD had a 9% mortality rate (3/33), not statistically significant compared to non-jaundiced patients.
- No deaths occurred after left-sided resections, irrespective of bilirubin levels.
Conclusions:
- PBD can be safely omitted in specific cases: jaundice <2-3 weeks, total bilirubin <200 µmol/l, no prior cholangiography, no sepsis, and future liver remnant >40%.
- These criteria apply to most left-sided resections and selected right-sided resections.
- PBD is indicated in other cases, potentially combined with portal vein embolization for small future liver remnants.
