Preoperative biliary drainage before resection for cholangiocarcinoma (Pro)

Area of Science:

• Hepatobiliary Surgery
• Surgical Oncology
• Gastroenterology

Background:

• Preoperative biliary drainage (BD) using percutaneous transhepatic (PTBD), endoscopic (EBD), or endoscopic nasobiliary (ENBD) approaches is considered before cholangiocarcinoma resection.
• Randomized controlled trials (RCTs) indicate that preoperative PTBD does not enhance perioperative outcomes.
• RCTs also suggest EBD offers no clear benefit for malignant obstructive jaundice and is associated with infectious complications in hilar cholangiocarcinoma.

Purpose of the Study:

• To evaluate the safety and efficacy of preoperative biliary drainage in patients undergoing major hepatectomy for hilar cholangiocarcinoma.
• To determine the role of preoperative BD in surgical planning and preventing complications in biliary cancer surgery.

Main Methods:

• Review of randomized controlled trials (RCTs) comparing different preoperative biliary drainage methods (PTBD, EBD, ENBD) before cholangiocarcinoma resection.
• Analysis of the impact of preoperative BD on perioperative results, infectious complications, and surgical planning.
• Consideration of outcomes for major hepatectomy with and without preoperative BD, particularly for hilar cholangiocarcinoma.

Main Results:

• Preoperative PTBD has not demonstrated improvement in perioperative results based on available RCTs.
• Preoperative EBD shows no significant benefit for malignant obstructive jaundice and is linked to increased infectious complications post-procedure for hilar cholangiocarcinoma.
• Selective cholangiography via ENBD/PTBD provides crucial anatomical detail for surgical planning in complex hilar cholangiocarcinoma cases.

Conclusions:

• While preoperative EBD may increase cholangitis risk, a strategy combining major hepatectomy with preoperative biliary drainage (preferably PTBD and/or ENBD), followed by portal vein embolization, is established as a safer approach for perihilar cholangiocarcinoma.
• Preoperative BD, particularly PTBD and ENBD, plays a vital role in precise anatomical mapping for complex resections in hilar cholangiocarcinoma.
• Further RCTs are needed to clarify the safety of major hepatectomy without preoperative BD for cholestatic hilar cholangiocarcinoma patients.