Endoscopic Nasobiliary Drainage Should be Initially Selected for Preoperative Biliary Drainage in Patients with Perihilar Bile Duct Cancer

Abstract

We read with interest the article by Hwang et al. [1] on the outcome after preoperative biliary drainage in patients with perihilar bile duct cancer. They reported an incidence of percutaneous transhepatic biliary drainage (PTBD) catheter tract recurrence (4/231, 1.7 %) lower than that reported by Takahashi et al. [2] (23/445, 5.2 %). We do not know the methods of endoscopic drainage, namely, endoscopic biliary stenting (EBS) or nasobiliary drainage (ENBD). Recently, we reported a single-center observational study of 128 consecutive patients undergoing preoperative biliary drainage [3] in which we compared the effectiveness of PTBD, EBS, and ENBD in patients with perihilar bile duct cancer. ENBD proved to be the most suitable preoperative biliary drainage method on the basis of the decompression period, complications, need to convert procedures, and postsurgical morbidity/ mortality. Limitations of the study included its retrospective design, small population, and data from only a single center. Catheter occlusion with acute cholangitis is a frequent complication associated with EBS, and PTBD may cause not only cancer dissemination (3/48, 6.3 %) as a lethal complication but also vascular injury (4/48, 8.3 %), which requires conversion of surgical procedures. Cancer dissemination associated with bile spillage during PTBD is an unavoidable complication, regardless of the physician’s expertise. Based on our results, we recommend ENBD in most patients expected to undergo radical surgery for perihilar bile duct cancer [3]. Takahashi et al. [2] showed that the prognosis of PTBD catheter tract recurrence is generally poor, even after resection, and that endoscopic biliary drainage is initially recommended when drainage is indicated. Thus, PTBD should be performed in only limited cases and as an optional procedure when ENBD is difficult [3–5]. We suggested that unilateral ENBD of the future remnant lobe is feasible in almost all patients and sufficient in most [3–5]. Indeed, Hwang performed mostly (69.3 %) single PTBD, which should be replaced with unilateral ENBD [1]. We usually discuss with surgeons and radiologists which side of the lobe should be drained before preoperative biliary drainage. We recently reported that bilateral ENBD is suitable for managing bilateral segmental cholangitis occurring in both hemilivers [5]. ENBD is theoretically inferior to EBS with regard to patient symptoms and disruption of the enterohepatic bile salt circulation. Throat discomfort was tolerable in most patients in our series, and collected bile was returned to the enterohepatic circulation, if needed. Thus, EBS should be avoided to reduce the frequency of acute obstructive cholangitis, which leads to significant, irreversible deterioration of the hepatic functional reserve [3, 5] during reduction of total bilirubin up to 2 mg/dl prior to surgery. Although we understand that complete biliary drainage of segmental bile ducts is not always possible endoscopically, ENBD is strongly recommended as the preferred preoperative biliary drainage method and for managing bilateral segmental cholangitis of resectable perihilar bile duct cancer [3–5]. Therefore, PTBD is an option only for patients in whom biliary drainage is technically difficult using an endoscopic approach, and its use should be limited. H. Kawakami (&) M. Kuwatani K. Eto T. Kudo Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo 060-8638, Japan e-mail: hiropon@med.hokudai.ac.jp