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World J Gastrointest Endosc. Mar 16, 2014; 6(3): 68-73
Published online Mar 16, 2014. doi: 10.4253/wjge.v6.i3.68
Preoperative biliary drainage in hilar cholangiocarcinoma: When and how?
Woo Hyun Paik, Nerenthran Loganathan, Jin-Hyeok Hwang
Woo Hyun Paik, Nerenthran Loganathan, Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736, South Korea
Jin-Hyeok Hwang, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do 463-707, South Korea
Author contributions: Paik WH reviewed the literature, and wrote and revised the manuscript; Loganathan N wrote and revised the manuscript; Hwang JH contributed to the conceptual design and critical revision of the manuscript.
Correspondence to: Jin-Hyeok Hwang, MD, PhD, Professor, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea. woltoong@snu.ac.kr
Telephone: +82-31-7877017 Fax: +82-31-7874051
Received: November 25, 2013
Revised: February 11, 2014
Accepted: March 3, 2014
Published online: March 16, 2014
Abstract

Hilar cholangiocarcinoma is a tumor of the extrahepatic bile duct involving the left main hepatic duct, the right main hepatic duct, or their confluence. Biliary drainage in hilar cholangiocarcinoma is sometimes clinically challenging because of complexities associated with the level of biliary obstruction. This may result in some adverse events, especially acute cholangitis. Hence the decision on the indication and methods of biliary drainage in patients with hilar cholangiocarcinoma should be carefully evaluated. This review focuses on the optimal method and duration of preoperative biliary drainage (PBD) in resectable hilar cholangiocarcinoma. Under certain special indications such as right lobectomy for Bismuth type IIIA or IV hilar cholangiocarcinoma, or preoperative portal vein embolization with chemoradiation therapy, PBD should be strongly recommended. Generally, selective biliary drainage is enough before surgery, however, in the cases of development of cholangitis after unilateral drainage or slow resolving hyperbilirubinemia, total biliary drainage may be considered. Although the optimal preoperative bilirubin level is still a matter of debate, the shortest possible duration of PBD is recommended. Endoscopic nasobiliary drainage seems to be the most appropriate method of PBD in terms of minimizing the risks of tract seeding and inflammatory reactions.

Keywords: Klatskin’s tumor, Management, Jaundice, Endoscopic biliary drainage, Percutaneous biliary drainage, Preoperative biliary drainage

Core tip: In selected patients, optimal preoperative management will improve the morbidity and mortality of hilar cholangiocarcinoma. Endoscopic nasobiliary drainage seems to be the most appropriate method of preoperative biliary drainage (PBD) in terms of minimizing the risk of tract seeding and inflammatory reactions. Percutaneous transhepatic biliary drainage could be a better option in certain cases such as advanced hilar cholangiocarcinoma or segmental cholangitis. Total biliary drainage is not usually recommended except in certain situations when the surgical technique is difficult without PBD or when patients develop cholangitis after unilateral drainage or a slow-resolving hyperbilirubinemia. Although the optimal preoperative bilirubin level is still a matter of debate, the shortest possible duration of PBD is recommended.