Pre-operative biliary drainage in hilar cholangiocarcinoma, benefits and risks, single center experience

Post-operative hepatic insufficiency is a critical complication after hepatic resection in jaundiced patients with hilar cholangiocarcinoma (hilar CC). Attempts to reduce the post operative risks associated with biliary obstruction by preoperative biliary drainage (PBD) remain controversial.

This study comparing 100 patients with hilar CC who underwent different types of hepatectomy with PBD (46%) [through percutaneous transhepatic drainage (PTD), endoscopic retrograde cholangiopancreatography (ERCP), or both] and without PBD (54%). Morbidity and mortality were analyzed.

Morbidity was 58.6% in the drained group and 20.3% in the undrained group (p = 0.001). Wound infection, abdominal collection and pneumonia were frequent in the drained group. Biliary leakage had a significant occurrence in the drained group (p = 0.02). Transfusion requirement was more common in the drained group (p = 0.04). Post operative hospital stay was prolonged in the drained group (p = 0.01). However, transient liver cell failure was more common in the undrained group (14.8% vs. 10.8%). In contrast, there were no significant differences for mortality (10.8% vs. 5.5%, p = 0.14), survival (22.6 +/- 17 vs. 19.7 +/- 16.6 months, p = 0.27) and recurrence (26% vs. 18.5%, p = 0.65).

Major liver resections in hilar CC without PBD are safe in most patients. PBD increases morbidity, biliary leakage, transfusion requirement and hospital stay. In our experience, PBD is recommended in selected patients with: cholangitis, long standing jaundice, impaired renal function and severe malnourishment state.