Debate continues over which method we should prefer for the preoperative biliary decompression in cases with hilar cholangiocarcinoma

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Springer 2011 We read with a great interest the article by Kawakami et al. [1] about the best preoperative biliary drainage methods in the management of patients with hilar cholangiocarcinoma (HCA). The authors compared the outcomes of endoscopic nasobiliary drainage (ENBD), endoscopic biliary stenting (EBS) and percutaneous transhepatic biliary drainage (PTBD) in a total of 128 patients. They noted that drainage tube occlusions with cholangitis were more common in the EBS group. They also found that the patients in the PTBD group experienced serious complications including portal vein injury (8%) and cancer dissemination (4%). Finally, they concluded that the ENBD procedure is the best and most suitable method for the initial biliary decompressive approach for the patients with HCA before the resective surgery procedure. Although the retrospective design of this study was already noted to be a limitation, we want to underline some concerns with the results of this study. Indeed, portal vein injury during ultrasound guided PTBD is a very rare occurrence [2]. However, in this report, we noticed a high rate of vascular injury associated with PTBD procedure. The authors did not link this high rate of portal vein injury during PTBD with any explanation in the text. However, we suggest that this complication can be associated with the use of 12–16 Fr tubes which were used for transhepatic cholangioscopy in this study. We think that the authors can provide data about this to make it more clear for the readers. The other flaw with the PTBD procedure is the high rate of tube dislodgement (14%) in this series of the patients. Again, we do not see this rate of tube dislodgement in our daily practice since we use a locked catheter system during internal–external drainage catheter placement to prevent the easy tube dislodgment problem. If the physicians doing the PTBD procedure in this study did not use this system, or they placed mostly external biliary drainage catheters, this might explain this high rate of catheter dislodgement. Thus, we wonder in how many cases they put external and internal catheters during the PTBD procedure. Another unclear point in this study is about their cases with cancer dissemination after the PTBD procedure. The authors indicated cancer dissemination in three patients (6.3%) in association with the PTBD. Although, the cholangiocarcinomas are highly fibrotic tumors with desmoplastic stroma, there is a potential risk of catheter tract implantation [3]. Catheter tract implantation metastasis after PTBD usually presents as subcutaneous nodules. However, it is not clearly indicated in the text how the authors diagnosed and linked cancer dissemination in these cases in association with the PTBD procedure.