Article

Journal of Hepato-Biliary-Pancreatic Surgery

, Volume 15, Issue 1, pp 25-30

First online:

Preoperative biliary drainage for biliary tract and ampullary carcinomas

  • Masato NaginoAffiliated withDivision of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine
  • , Tadahiro TakadaAffiliated withDepartment of Surgery, Teikyo University School of Medicine
  • , Masaru MiyazakiAffiliated withDepartment of General Surgery, Chiba University Graduate School of Medicine
  • , Shuichi MiyakawaAffiliated withDepartment of Gastroenterological Surgery, Fujita Health University
  • , Kazuhiro TsukadaAffiliated withDepartment of Surgery and Science, Graduate School of Medicine and Pharmaceutical Science for Research, University of Toyama
  • , Satoshi KondoAffiliated withDepartment of Surgical Oncology, Hokkaido University Graduate School of Medicine
  • , Junji FuruseAffiliated withHepatobiliary and Pancreatic Oncology Division, National Cancer Center Hospital East
  • , Hiroya SaitoAffiliated withDepartment of Radiology, Asahikawa Kosei General Hospital
  • , Toshio TsuyuguchiAffiliated withDepartment of Medicine and Clinical Oncology, Chiba University Graduate School of Medicine
    • , Tatsuya YoshikawaAffiliated withTokyo Metropolitan Health and Medical Treatment Corporation, Ebara Hospital
    • , Tetsuo OhtaAffiliated withDepartment of Gastroenterologic Surgery, School of Medicine, Kanazawa University
    • , Fumio KimuraAffiliated withDepartment of General Surgery, Chiba University Graduate School of Medicine
    • , Takehiro OhtaAffiliated withDepartment of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University
    • , Hideyuki YoshitomiAffiliated withDepartment of General Surgery, Chiba University Graduate School of Medicine
    • , Satoshi NozawaAffiliated withDepartment of General Surgery, Chiba University Graduate School of Medicine
    • , Masahiro YoshidaAffiliated withDepartment of Surgery, Teikyo University School of Medicine
    • , Keita WadaAffiliated withDepartment of Surgery, Teikyo University School of Medicine
    • , Hodaka AmanoAffiliated withDepartment of Surgery, Teikyo University School of Medicine
    • , Fumihiko MiuraAffiliated withDepartment of Surgery, Teikyo University School of Medicine

Abstract

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.

Key words

Biliary Drainage Endoscopy Percutaneous Bile replacement Guidelines