Preoperative biliary drainage in hilar cholangiocarcinoma: Systematic review and meta-analysis

doi:10.1016/j.ejso.2017.04.001

European Journal of Surgical Oncology

Volume 43, Issue 9, September 2017, Pages 1628-1635

https://doi.org/10.1016/j.ejso.2017.04.001 Get rights and content

Abstract

Background

The role of preoperative biliary drainage (PBD) for hilar cholangiocarcinoma (HCC) remains unclear. The aim of this meta-analysis is to investigate the role of PBD in the treatment of potentially resectable HCC.

Methods

All studies reporting outcomes on patients with PBD vs without PBD were included. A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1980 and 2016.

Results

Initial search identified 667 articles. Only 9 studies met the inclusion criteria and were included in this analysis. No significant differences in mortality were observed between the two groups (RR = 0,935; 95% CI = 0,612 to 1429; p = 0,463). Overall morbidity was significantly higher in PBD group (RR = 1266; 95% CI = 1039 to 1543; p = 0,011). No significant differences in transfusion rate, hospital stay, anastomotic leaks, abdominal collections and operative time, were found. Wound infections were significantly higher in PBD group.

Conclusions

PBD seems to be associated with higher postoperative morbidity and increases the risk of wound infections. Further prospective studies are needed to better define the impact of PBD in outcomes after surgery for hilar cholangiocarcinoma.

Introduction

Hilar cholangiocarcinoma (HCC) is a rare malignancy, firstly described in 1965.¹

In Western countries, its incidence is low, but in Asia it could reach 113 per 100,000 men and 50 per 100,000 women.² Most patient presents biliary symptoms, painless jaundice; cachexia and fatigue may be more often associated with a locally advanced or metastatic disease.1, 2, 3, 4

Surgery, which is the key treatment for HCC, is very challenging.

Liver resection with jaundice has always been considered a potentially dangerous procedure, due to the higher risk of bleeding, sepsis and liver failure.⁵

However, nowadays, the use of preoperative biliary drainage in jaundice patients remains one of the most debated issues, in the management of this tumor.

In fact, considering that preoperative biliary drainage (PBD) is a procedure that is not exempt from risks (cholangitis, extended pre-operative hospital stay, failure to improve the nutritional state, increased post-operative complications), many authors try to understand whether its use should always be mandatory.6, 7

Despite that, the majority of patients referred to specialized centers have already undergone drainage before referral.8, 9

Recently two meta-analyses that investigated the efficacy of preoperative biliary drainage in malignant jaundice, revealed conflicting results: in the analysis of Chen et al.¹⁰ PBD was associated with increased post-operative infective complications in patients with pancreatic carcinoma, while Moole et al.¹¹ showed significantly less major adverse events in the drained group, in patients with liver or pancreatic carcinoma.

The aim of this study is to investigate the role of PBD in the treatment of patients with potentially resectable hilar cholangiocarcinoma (HCC), analyzing the published data comparing the postoperative outcomes in patients with or without PBD.

Section snippets

Study selection

The study was designed according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines published in 2010.¹² A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1980 and 2016. Search terms used were “hilar cholangiocarcinoma” AND (((preoperative AND (“biliary drainage” OR cholangiogra*)) OR PTB OR PTBD) OR (preoperative AND “endoscopic retrograde biliary drainage” OR cholangiopancreatography

Literature search and assessment of methodological quality

Database search and manual screening of reference lists yielded a total of 667 potentially relevant articles. The process of study selection was reported in Fig. 1. Nine studies, involving a total of 892 patients, with potentially resectable hilar cholangiocarcinoma, were eligible for data extraction and were therefore included in this review. 501 patients had PBD (52,2%) while 391 were not drained (43,8%). The methodological quality of the included studies is summarized in Table 1. The date of

Discussion

For several years jaundice and cholangitis have been considered the most important risk factors for hepatic failure and infective complications in liver surgery. Thus, the use of preoperative biliary drainage for hilar cholangiocarcinoma (HCC) has been widely adopted in several hepatobiliary centers.

However, the lack of standardized recommendations, ensures different attitudes in each centers: a few surgeons suggested that PBD is not beneficial in the routine management of this tumor, but could

Conclusions

Preoperative biliary drainage may be associated with higher overall morbidity, due to the risk of infective complications. Further prospective studies are needed to better define the impact of PBD in outcomes after surgery for hilar cholangiocarcinoma.

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Preoperative endoscopic biliary drainage by metal versus plastic stents for resectable perihilar cholangiocarcinoma
2024, Gastrointestinal Endoscopy
Adequate preoperative biliary drainage (PBD) is recommended in most patients with resectable perihilar cholangiocarcinoma (pCCA). Most expert centers use endoscopic plastic stents rather than self-expandable metal stents (SEMSs). In the palliative setting, however, use of SEMSs has shown longer patency and superior survival. The aim of this retrospective study was to compare stent dysfunction of SEMSs versus plastic stents for PBD in resectable pCCA patients.
In this multicenter international retrospective cohort study, patients with potentially resectable pCCAs who underwent initial endoscopic PBD from 2010 to 2020 were included. Stent failure was a composite end point of cholangitis or reintervention due to adverse events or insufficient PBD. Other adverse events, surgical outcomes, and survival were recorded. Propensity score matching (PSM) was performed on several baseline characteristics.
A total of 474 patients had successful stent placement, of whom 61 received SEMSs and 413 plastic stents. PSM (1:1) resulted in 2 groups of 59 patients each. Stent failure occurred significantly less in the SEMSs group (31% vs 64%; P < .001). Besides less cholangitis after SEMSs placement (15% vs 31%; P = .012), other PBD-related adverse events did not differ. The number of patients undergoing surgical resection was not significantly different (46% vs 49%; P = .71). Complete intraoperative SEMSs removal was successful and without adverse events in all patients.
Stent failure was lower in patients with SEMSs as PBD compared with plastic stents in patients with resectable pCCA. Removal during surgery was quite feasible. Surgical outcomes were similar.
Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma
2024, European Journal of Surgical Oncology
Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how ‘resectable’ disease is defined – molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.
Results from the european survey on preoperative management and optimization protocols for PeriHilar cholangiocarcinoma
2023, HPB
Major surgery, along with preoperative cholestasis-related complications, are responsible for the increased risk of morbidity and mortality in perihilar cholangiocarcinoma (pCCA). The aim of the present survey is to provide a snapshot of current preoperative management and optimization strategies in Europe.
61 European centers, experienced in hepato-biliary surgery completed a 59-questions survey regarding pCCA preoperative management. Centers were stratified according to surgical caseload (<5 and ≥ 5 cases/year) and preoperative management protocols’ application.
The overall case volume consisted of 6333 patients. Multidisciplinary discussion was routinely performed in 91.8% of centers. Most respondents (96.7%) recognized the importance of a well-structured preoperative protocol. The preferred method for biliary drainage was percutaneous transhepatic biliary drainage (60.7%) while portal vein embolization was the preferred technique for liver hypertrophy (90.2%). Differences in preoperative pathologic confirmation of malignancy (35.8% vs 28.7%; p < 0.001), number of mismanaged referred patients (88.2% vs 50.8%; p < 0.001), biliary drainage (65.1% vs 55.6%; p = 0.015) and liver function evaluation (37.2% vs 5.6%; p = 0.001) were found between centers according to groups’ stratification.
The importance of a correct preoperative management is recognized. Nevertheless, the current lack of guidelines leads to wide heterogeneity of behaviors among centers. This survey can provide recommendations to improve pCCA perioperative outcomes.
Should more aggressive surgical resection be considered in the treatment for Bismuth types I and II hilar cholangiocarcinoma? A meta-analysis
2023, Asian Journal of Surgery
Evidence regarding the optical surgical extent for Bismuth type I/II HCCA is lacking. we aims to evaluate the optimal surgical methods for Bismuth type I/II HCCA. Studies comparing bile duct resection (BDR) and BDR combined with liver resection (BDR + LR) for all types of HCCA patients were searched for analyses, and 14 studies were finally included. The main outcomes were the R0 resection rate and overall survival (OS). For all types of HCCA patents, BDR + LR resulted with higher R0 resection rates when comparing with BDR only (RR = 0.70, 95%CI, 0.63–0.78), and patients with R0 resections had eight times longer median survival and more long-time survival outcomes (3 and 5 year OS) comparing to those with non-R0 resections. Bismuth I/II HCCA patients also showed longer median survival and 3-year OS after R0 resections (P = 0.04). Moreover, there was no significant difference in 3-year OS between BDR and BDR + LR (P = 0.89) and we additionally found BDR resulted in less mortality or morbidity rates. In Europe and US, they resulted the R0 resection rates could be comparable between BDR and BDR + LR (P = 0.18), and Bismuth type I HCCA accounted for 75.8%, while in Asia, BDR + LR still resulted with higher R0 resection rates (P < 0.0001) and the Bismuth type I HCCA accounted for only 40.3%. The surgical approaches may not directly impact patient prognosis, patients with R0 resections are usually associated with improved survival outcomes; for selected Bismuth type I/II HCCA, BDR may be an acceptable option with regard to lower morbidity and comparable R0 resection rate comparing with BDR + LR.
Pathogen detection in patients with perihilar cholangiocarcinoma: Implications for targeted perioperative antibiotic therapy
2023, Hepatobiliary and Pancreatic Diseases International
Cholestasis should be relieved by biliary drainage prior to major liver resection. This condition is often associated with bacterial colonization of the otherwise sterile biliary system. Cholangitis reduces the regenerative capacity of the remaining liver. Therefore, targeted antibiotic therapy is a key feature in perioperative treatment in patients with perihilar cholangiocarcinoma (pCCC).
Between December 1999 and December 2017, 251 pCCC patients were treated in our center. In total, 115 patients underwent a microbiological analysis. In addition to the characterization of the specific microorganisms and antibiotic resistance, we analyzed subgroups according to preoperative intervention.
Enterococci (87/254, 34%) and Enterobacteria (65/254, 26%) were the most frequently detected genera. In 43% (50/115) of patients, Enterococcus faecalis was found in the bile duct sample. Enterococcus faecium (29/115) and Escherichia coli (29/115) were detected in 25% of patients. In patients with percutaneous transhepatic biliary drainage (3/8, 38%) or stents (24/79, 30%), Enterococcus faecium was diagnosed most frequently (P < 0.05). Enterococcus faecium and Klebsiella oxytoca were significantly more frequently noted in the time period after 2012 (P < 0.05). With regard to fungal colonization, the focus was on various Candida strains, but these strains generally lacked resistance.
pCCC patients exhibit specific bacterial colonization features depending on the type of preoperative biliary intervention. Specifically, targeted antibiosis should be applied in this patient cohort to minimize the risk of biliary complications after major liver resection. In our cohort, the combination of meropenem and vancomycin represents an effective perioperative medical approach.
Infectious complications after surgery for perihilar cholangiocarcinoma: A single Western center experience
2022, Surgery (United States)
The aim of this study was to analyze the risk factors for surgical infectious complications and the outcomes of patients undergoing surgery for perihilar cholangiocarcinoma according to the microbiological examinations.
Patients who underwent surgery for perihilar cholangiocarcinoma in the last decade were enrolled, and all clinical and microbiological data were collected from a retrospective monocentric database. Univariate and multivariate analyses were performed distinguishing patients who developed at least 1 surgical infectious complication (surgical site infections, acute bacterial cholangitis, bacteremia).
A total of 98 patients were included. Among patients who developed surgical infectious complications (51%), many preoperative characteristics were significantly more frequent: American Society of Anesthesiologists score ≥3 (P = .026), neutrophil-to-lymphocyte ratio ≥3.4 (P = .001), endoscopic sphincterotomy (P = .032), ≥2 biliary drainage procedures (P = .013), acute cholangitis (P = .012), multidrug resistant (P = .009), and ≥3 microorganisms’ detection (P = .042); whereas during the postoperative period, surgical infectious complications were associated to increased incidence of intensive care unit readmission (P = .031), major complications (P < .001), posthepatectomy liver failure (P = .005), ascites (P = .008), biliary leakage (P = .008), 90-day readmission (P = .003), and prolonged length of hospital stay (P < .001). At the multivariate analysis 3 independent preoperative risk factors for surgical infectious complications were identified: neutrophil-to-lymphocyte ratio ≥3.4 (P = .004), endoscopic sphincterotomy (P = .009), and acute cholangitis (P = .013). The presence of multidrug-resistance in the perioperative biliary cultures was related to postoperative multidrug-resistant species from all cultures (P < .001) and organ/space and incisional–surgical site infections (P ≤ .044).
Infective complications after surgery for perihilar cholangiocarcinoma worsen the short-term outcomes. A careful microbiological surveillance should be carried out in all cases to prevent and promptly treat surgical infectious complications.

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ReviewPreoperative biliary drainage in hilar cholangiocarcinoma: Systematic review and meta-analysis

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study selection

Literature search and assessment of methodological quality

Discussion

Conclusions

Am J Med

HPB (Oxford)

J Gastrointest Surg

J Gastrointest Surg

Int J Surg

Cir Esp

J Am Coll Surg

Surgery

HPB (Oxford)

HPB (Oxford)

Surg Oncol Clin N Am

HPB (Oxford)

HPB (Oxford)

HPB (Oxford)

Risk factors for cholangiocarcinoma

Hepatology

Preoperative management of hilar cholangiocarcinoma

J Hepatobil Pancreat Surg

Preoperative biliary drainage in hilar cholangiocarcinoma: when and how?

World J Gastrointest Endosc

Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost?

Ann Surg

Biliary drainage in obstructive jaundice: experimental and clinical aspects

Br J Surg

Effect of preoperative biliary drainage on complications following pancreatoduodenectomy: a meta-analysis

Medicine (Baltimore)

Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review

World J Surg Oncol

Review
Preoperative biliary drainage in hilar cholangiocarcinoma: Systematic review and meta-analysis