Surgical Endoscopy

, Volume 31, Issue 1, pp 422–429 | Cite as

Best options for preoperative biliary drainage in patients with Klatskin tumors

  • Jung Hyun Jo
  • Moon Jae ChungEmail author
  • Dai Hoon Han
  • Jeong Youp Park
  • Seungmin Bang
  • Seung Woo Park
  • Si Young Song
  • Jae Bock Chung


Summary background data

Operative treatment combined with PBD has been established as a safe management strategy for Klatskin tumors. However, controversy exists regarding the preferred technique for PBD among percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary stenting (EBS), and endoscopic nasobiliary drainage (ENBD). This study aimed to identify the best technique for preoperative biliary drainage (PBD) in Klatskin tumor patients.


This study evaluated 98 Klatskin tumor patients who underwent PBD prior to operation with a curative aim between 2005 and 2012. The PTBD, EBS, and ENBD groups included 43, 42, and 13 patients, respectively. Baseline characteristics, technical success rate, complications of PBD, and surgical outcomes were compared.


Initial technical success rates (97.3 %, PTBD; 90.2 %, endoscopic methods, including EBS and ENBD) and mean duration until biliary decompression (31.0, PTBD; 28.7, EBS; 35.8 days, ENBD) were not significantly different between the groups. Total frequency of complications did not significantly differ between the EBS group (42.9 %) and the PTBD (27.9 %, p = 0.149) and ENBD (15.4 %, p = 0.072) groups. The ENBD group showed a significantly higher rate of conversion to other methods (76.9 %) than the PTBD (4.7 %, p < 0.0001) and EBS (35.7 %, p = 0.009) groups.


PTBD, EBS, and ENBD showed comparable results regarding initial technical success rates, complication rates, and surgical outcomes. As Klatskin tumor patients must undergo PBD prior to 3 weeks before surgery, PTBD and ENBD are uncomfortable and disadvantageous in terms of compliance. EBS was the most suitable method for initial PBD in terms of compliance among Klatskin tumor patients.


Klatskin tumors Preoperative biliary drainage Percutaneous transhepatic biliary drainage Endoscopic biliary stenting Endoscopic nasobiliary drainage 


Compliance with ethical standards


Jung Hyun Jo, Moon Jae Chung, Dai Hoon Han, Jeong Youp Park, Seungmin Bang, Seung Woo Park, Si Young Song, and Jae Bock Chung have no conflicts of interest or financial ties to disclose.


  1. 1.
    Valero V 3rd, Cosgrove D, Herman JM, Pawlik TM (2012) Management of perihilar cholangiocarcinoma in the era of multimodal therapy. Expert Rev Gastroenterol Hepatol 6:481–495CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Jarnagin WR, Fong Y, DeMatteo RP, Gonen M, Burke EC, Bodniewicz BJ, Youssef BM, Klimstra D, Blumgart LH (2001) Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 234:507–517 (discussion 517–509) CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Silva MA, Tekin K, Aytekin F, Bramhall SR, Buckels JA, Mirza DF (2005) Surgery for hilar cholangiocarcinoma; a 10 year experience of a tertiary referral centre in the UK. Eur J Surg Oncol 31:533–539CrossRefPubMedGoogle Scholar
  4. 4.
    Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, Madhusudan S, Iveson T, Hughes S, Pereira SP, Roughton M, Bridgewater J, Investigators ABCT (2010) Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med 362:1273–1281CrossRefPubMedGoogle Scholar
  5. 5.
    Cherqui D, Benoist S, Malassagne B, Humeres R, Rodriguez V, Fagniez PL (2000) Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage. Arch Surg 135:302–308CrossRefPubMedGoogle Scholar
  6. 6.
    Hochwald SN, Burke EC, Jarnagin WR, Fong Y, Blumgart LH (1999) Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 134:261–266CrossRefPubMedGoogle Scholar
  7. 7.
    Rea DJ, Munoz-Juarez M, Farnell MB, Donohue JH, Que FG, Crownhart B, Larson D, Nagorney DM (2004) Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients. Arch Surg 139:514–523 (discussion 523–515) CrossRefPubMedGoogle Scholar
  8. 8.
    Kawasaki S, Imamura H, Kobayashi A, Noike T, Miwa S, Miyagawa S (2003) Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Ann Surg 238:84–92PubMedPubMedCentralGoogle Scholar
  9. 9.
    Ratti F, Cipriani F, Ferla F, Catena M, Paganelli M, Aldrighetti LA (2013) Hilar cholangiocarcinoma: preoperative liver optimization with multidisciplinary approach. Toward a better outcome. World J Surg 37:1388–1396CrossRefPubMedGoogle Scholar
  10. 10.
    Walter T, Ho CS, Horgan AM, Warkentin A, Gallinger S, Greig PD, Kortan P, Knox JJ (2013) Endoscopic or percutaneous biliary drainage for Klatskin tumors? J Vasc Interv Radiol 24:113–121CrossRefPubMedGoogle Scholar
  11. 11.
    Kloek JJ, van der Gaag NA, Aziz Y, Rauws EA, van Delden OM, Lameris JS, Busch OR, Gouma DJ, van Gulik TM (2010) Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg 14:119–125CrossRefPubMedGoogle Scholar
  12. 12.
    Kawakami H, Kuwatani M, Onodera M, Haba S, Eto K, Ehira N, Yamato H, Kudo T, Tanaka E, Hirano S, Kondo S, Asaka M (2011) Endoscopic nasobiliary drainage is the most suitable preoperative biliary drainage method in the management of patients with hilar cholangiocarcinoma. J Gastroenterol 46:242–248CrossRefPubMedGoogle Scholar
  13. 13.
    Takahashi Y, Nagino M, Nishio H, Ebata T, Igami T, Nimura Y (2010) Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma. Br J Surg 97:1860–1866CrossRefPubMedGoogle Scholar
  14. 14.
    Paik WH, Loganathan N, Hwang JH (2014) Preoperative biliary drainage in hilar cholangiocarcinoma: when and how? World J Gastrointest Endosc 6:68–73CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Bismuth H, Nakache R, Diamond T (1992) Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 215:31–38CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Ekkelenkamp VE, de Man RA, Ter Borg F, Borg PC, Bruno MJ, Groenen MJ, Hansen BE, van Tilburg AJ, Rauws EA, Koch AD (2015) Prospective evaluation of ERCP performance: results of a nationwide quality registry. Endoscopy 47:503–507CrossRefPubMedGoogle Scholar
  17. 17.
    Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, Riley SA, Veitch P, Wilkinson ML, Williamson PR, Lombard M (2007) Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 39:793–801CrossRefPubMedGoogle Scholar
  18. 18.
    Rerknimitr R, Angsuwatcharakon P, Ratanachu-ek T, Khor CJ, Ponnudurai R, Moon JH, Seo DW, Pantongrag-Brown L, Sangchan A, Pisespongsa P, Akaraviputh T, Reddy ND, Maydeo A, Itoi T, Pausawasdi N, Punamiya S, Attasaranya S, Devereaux B, Ramchandani M, Goh KL, Asia-Pacific Working Group on Hepatobiliary C (2013) Asia–Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol Hepatol 28:593–607CrossRefPubMedGoogle Scholar
  19. 19.
    Kawakami H, Kondo S, Kuwatani M, Yamato H, Ehira N, Kudo T, Eto K, Haba S, Matsumoto J, Kato K, Tsuchikawa T, Tanaka E, Hirano S, Asaka M (2011) Preoperative biliary drainage for hilar cholangiocarcinoma: which stent should be selected? J Hepatobiliary Pancreat Sci 18:630–635CrossRefPubMedGoogle Scholar
  20. 20.
    Yoshida Y, Ajiki T, Ueno K, Shinozaki K, Murakami S, Okazaki T, Matsumoto T, Matsumoto I, Fukumoto T, Usami M, Ku Y (2014) Preoperative bile replacement improves immune function for jaundiced patients treated with external biliary drainage. J Gastrointest Surg 18:2095–2104CrossRefPubMedGoogle Scholar
  21. 21.
    Hirano S, Tanaka E, Tsuchikawa T, Matsumoto J, Kawakami H, Nakamura T, Kurashima Y, Ebihara Y, Shichinohe T (2014) Oncological benefit of preoperative endoscopic biliary drainage in patients with hilar cholangiocarcinoma. J Hepatobiliary Pancreat Sci 21:533–540CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Jung Hyun Jo
    • 1
  • Moon Jae Chung
    • 1
    Email author
  • Dai Hoon Han
    • 2
  • Jeong Youp Park
    • 1
  • Seungmin Bang
    • 1
  • Seung Woo Park
    • 1
  • Si Young Song
    • 1
  • Jae Bock Chung
    • 1
  1. 1.Division of Gastroenterology, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulKorea
  2. 2.Department of Surgery, Severance HospitalYonsei University College of MedicineSeoulKorea

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