Preoperative biliary drainage in patients with hilar cholangiocarcinoma undergoing major hepatectomy

Table 1 Baseline characteristics n (%)

	Drained (n = 32)	Undrained (n = 46)	P value
Age (yr)	59.6 ± 11.0	58.2 ± 11.3	0.568
Sex (M/F)	21/11	28/18	0.669
Body mass index (kg/m2)	20.3 ± 1.9	21.0 ± 2.5	0.190
Concomitant diseases
Diabetes	2 (6.3)	3 (6.5)	1.000
Hypertension	3 (9.4)	7 (15.2)	0.678
Cardiovascular	2 (6.3)	5 (10.9)	0.765
Previous history of abdominal surgery	9 (28.1)	12 (26.1)	0.842
Serum total bilirubin (μmol/L)
At admission	294.2 ± 135.7	254.0 ± 63.5	0.126
Before surgery	108.1 ± 60.6	265.7 ± 69.1	0.000
Time of PBD (d)	15.3 ± 3.4	-	-
Time between admission and surgery (d)	20.7 ± 2.1	3.8 ± 1.6	0.000
Portal vein embolization	5 (15.6)	3 (6.5)	0.355
Bismuth–Corlette classification
I	1 (3.1)	1 (2.2)	1.000
II	8 (25)	14 (30.4)	0.600
IIIa	6 (18.8)	7 (15.2)	0.680
IIIb	9 (28.1)	15 (32.6)	0.673
IV	8 (25)	9 (19.6)	0.567
Perioperative details
Hilar bile duct resection	32 (100)	46 (100)	-
Left hepatectomy	17 (53.1)	31 (67.4)	0.203
Extended left hepatectomy	2 (6.3)	1 (2.2)	0.747
Right hepatectomy	8 (25)	10 (21.7)	0.737
Extended right Hepatectomy	5 (15.6)	4 (8.7)	0.561
Caudate lobectomy	8 (25)	12 (26.1)	0.914
Pedicle clamping	17 (53.1)	26 (56.5)	0.767
Portal vein resection	6 (18.8)	8 (17.4)	0.878
Hepatic artery resection	2 (6.3)	3 (6.5)	1.000
Number of blood Transfusions	11 (34.4)	24 (52.2)	0.120
Intraoperative blood transfusion (mL)	900 (800-900)	800 (600-1100)	0.513

PBD: Preoperative biliary drainage.

Table 2 Postoperative outcomes of patients undergoing major hepatectomy n (%)

	Drained (n = 32)	Undrained (n = 46)	P value
Morbidity	17 (53.1)	27 (58.7)	0.626
Infectious morbidity	13 (40.6)	11 (23.9)	0.116
Intra-abdominal abscess (II-IIIa)	3 (9.4)	2 (4.3)	0.673
Wound infection (I-IIIb)	4 (12.5)	4 (8.7)	0.869
Cholangitis (II)	1 (3.1)	2 (4.3)	1.000
Sepsis (IVa-V)	2 (6.3)	1 (2.2)	0.747
Lung infection (II)	6 (18.8)	5 (10.9)	0.325
Noninfectious morbidity	10 (31.3)	22 (47.8)	0.143
Liver failure (II-V)	3 (9.4)	6 (13)	0.890
Bile leak
Remnant liver1 (II-IIIa)	2 (6.3)	4 (8.7)	1.000
Anastomotic leak2 (II-IIIb)	1 (3.1)	2 (4.3)	1.000
Abdominal collection (I-IIIa)	6 (18.8)	9 (19.6)	0.928
Gastrointestinal bleeding (IIIa-V)	0	2 (4.3)	0.510
Abdominal bleeding (II-IIIb)	1 (3.1)	2 (4.3)	1.000
Respiratory failure (IVa)	0	3 (6.5)	0.265
Renal failure (IVa-V)	3 (9.4)	4 (8.7)	1.000
Mortality (V)	3 (9.4)	2 (4.3)	0.673
Reoperation	2 (6.3)	3 (6.5)	1.000
Postoperative hospital stay (d)	16.5 (13.5-20.5)	15 (12-18)	0.221

Clavien-Dindo grades of surgical complications are within parentheses.

¹From remnant liver;

²From hepaticojejunostomy.

Table 3 The risk factors for postoperative complications n (%)

Variable	n	Incidence of complications	Univariate	Multivariate
			P value	OR	P value
Age (yr)
> 60	38	21 (55.3)	0.842
≤ 60	40	23 (57.5)
Sex
Male	49	25 (51)	0.212
Female	29	19 (65.5)
PBD
Yes	32	17 (53.1)	0.626
No	46	27 (58.7)
Concomitant diseases
Yes	20	14 (70)	0.155
No	58	30 (51.7)
Previous abdominal surgery
Yes	21	11 (52.4)	0.663
No	57	33 (57.9)
Preoperative TBIL
> 170 μmol/L	48	32 (66.7)	0.021	13.690 (1.275-147.028)	0.031
≤ 170 μmol/L	30	12 (40)
Preoperative AST
> 100 U/L	47	31 (66)	0.036	1.138 (0.157-8.225)	0.898
≤ 100 U/L	31	13 (41.9)
Preoperative ALT
> 100 U/L	44	29 (65.9)	0.054	5.664 (0.595-53.905)	0.131
≤ 100 U/L	34	15 (44.1)
Preoperative ALB
> 35	41	26 (63.4)	0.189
≤ 35	37	18 (48.6)
Bismuth–Corlette stage
I and II	24	9 (37.5)	0.025	0.013 (0.001-0.166)	0.001
III and IV	54	35 (64.8)
Extended liver resection
Yes	12	11 (91.7)	0.018	14.010 (1.130-173.646)	0.04
No	66	33 (50)
Caudate lobectomy
Yes	20	12 (60)	0.707
No	58	32 (55.2)
Pedicle clamping
Yes	43	22 (51.2)	0.300
No	35	22 (62.9)
Vascular resections
Yes	19	13 (68.4)	0.225
No	59	31 (52.5)
Additional surgery
Yes	6	3 (50)	0.742
No	72	41 (56.9)
Intraoperative blood transfusion
Yes	35	19 (54.3)	0.644
No	43	25 (59.5)

TBIL: Total bilirubin; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALB: Albumin; PBD: Preoperative biliary drainage.

Table 4 Studies including resections for hilar cholangiocarcinoma with and without preoperative biliary drainage n (%)

Ref.	Year	Country	Design	Type of PBD	Surgical procedures for included patients	PBD	n	Morbidity	P value	Mortality	P value
Su et al[10]	1996	China	Retro	PTCD	CR and PR	Yes	33	17 (51.5)	NS	5 (15.2)	NS
						No	16	6 (37.5)		0
Takada et al[37]	1996	Japan	Retro	PTCD	CR	Yes	24	NA	-	3 (12.5)	NS
						No	12	NA		6 (50)
Hochwald et al[19]	1999	United States	Pro	PTCD	CR and PR	Yes	42	36 (85.7)	0.045	2 (4.8)	NS
				EBD		No	29	19 (65.5)		4 (14.3)
Figueras et al[31]	2000	Spain	Retro	PTCD	CR	Yes	11	11 (100)	NS	1 (9)	NS
						No	9	6 (66)		2 (22.2)
Parks et al[36]	2000	United Kingdom	Retro	PTCD	CR and PR	Yes	20	11 (55)	NS	1 (5)	NS
				EBD		No	27	11 (40.7)		1 (3.7)
Gerhards et al[5]	2000	The Netherlands	Retro	PTCD	CR	Yes	93	59 (63)	NS	16 (17)	NS
				EBD		No	18	13 (72)		3 (17)
Dinant et al[33]	2006	The Netherlands	Retro	PTCD	CR	Yes	83	56 (67.5)	NS	14 (16.7)	NS
				EBD		No	14	6 (42.9)		2 (14.3)
Li et al[32]	2009	China	Retro	PTCD	CR and PR	Yes	55	20 (36.3)	NS	4 (7.3)	NS
						No	56	16 (28.6)		5 (8.9)
Ferrero et al[18]	2009	Italy	Retro	PTCD	CR	Yes	30	21 (70)	NS	1 (3)	NS
				EBD		No	30	19 (63)		3 (10)
				SD
Ercolani et al[34]	2010	Italy	Retro	PTCD	CR and PR	Yes	44	25 (56.8)	NS	NA	-
				EBD		No	7	2 (28.5)		NA
El-Hanafy et al[20]	2010	Egypt	Retro	PTCD	CR	Yes	46	27 (58.6)	0.001	5 (10.8)	NS
				EBD		No	54	11 (20.3)		3 (5.5)
Yu et al[35]	2012	China	Retro	PTCD with bile re-infusion	CR and PR	Yes	48	14 (29.2)	0.036	1 (2.1)	NS
						No	39	20 (51.3)		2 (5.1)
Farges et al[14]	2013	France and Belgium	Retro	PTCD	CR	Yes	180	123 (68.3)	NS	17 (9.4)	NS
				EBD		No	186	128 (68.8)		22 (11.8)
Present study		China	Retro	PTCD	CR	Yes	32	17 (53.1)	NS	3 (9.4)	NS
				EBD		No	46	27 (58.7)		2 (4.3)
				SD

Retro: Retrospective; Pro: Prospective; PBD: Preoperative biliary drainage; PTCD: Percutaneous transhepatic cholangio-drainage; EBD: Endoscopic biliary drainage; SD: Surgical drainage; CR: Curative resection; PR: Palliative resection; NA: Not available; NS: Not significant.