Role of Preoperative Biliary Drainage in Resectable Hilar Cholangiocarcinoma

Background: To review the literature to investigate indications, advantages and complications of the different procedures for biliary drainage (percutaneous or endoscopic techniques) for resectable hilar cholangiocarcinoma. Methods: Pubmed and Medline databases were interrogated for articles published between January 1970 and November 2014. After screening for relevance, 56 articles were selected for the review. Results: Hilar cholangiocarcinoma is the most common primitive adenocarcinoma of the bile ducts, involving the proximal extra hepatic biliary system. Prognosis has been strongly related to tumour's resectability and extended combined hepatic and biliary resections are often required in order to achieve radical margin and survival benefit. Obstructive jaundice is the most common clinical presentation; preoperative hyperbilirubinemia is an independent risk factor for increased operative morbidity and mortality. Conclusion: PBD was shown to be helpful only in those patients having a bilirubin level greater than 3-10 mg/dl; we might conclude that PBD is probably useless with bilirubin level below 3 mg/dl, advisable between 3-10 mg/dl and mandatory above 10 mg/dl especially in patients undergoing an extended hepatic resection. In the initial management of HC, ENBD should be preferred as it is characterized by a less invasive approach and less complications (lower morbidity) . In case of suboptimal jaundice regression or in presence of complications PTBD might be combined, leaving EBD as last option. Drain should be limited to FLR. The optimal drain duration is debated: the drain should be left in place the time needed to reduce bilirubin level, meanly 2-6 weeks.