Preoperative biliary drainage: optimal method from a viewpoint of surgeon

Abstract

Hepatectomy for biliary tract cancer is well-known as a high-risk surgical procedure potentially yielding a high morbidity and mortality. Preoperative biliary drainage (PBD) has been routinely used in Japan, which totally conflicts to the indication in the West. However, recent studies demonstrated that PBD reduced the incidence of liver failure and mortality after right or more extended hepatectomy. Percutaneous transhepatic biliary drainage (PTBD) increased the incidences of catheter tract seeding and disseminated disease, thereby reducing postsurgical survival. This observation revises a PBD-strategy from percutaneous approach to endoscopic one, particularly in Japan. In addition, because preoperative cholangitis is highly associated with postoperative mortality, PBD should be chosen on the basis of the potential risk of procedure-related cholangitis. The first-line PBD is endoscopic naso-biliary drainage in Japan; endoscopic biliary stent or percutaneous biliary drainage in the overseas. Thus, the strategy of PBD still differ among regions or hospitals due to lack in scientific evidence.