Survey of preoperative management protocol for perihilar cholangiocarcinoma at 10 Japanese high-volume centers with a combined experience of 2,778 cases.

Abstract

In Japan, strategies for preoperative management of perihilar cholangiocarcinoma (PHC) have evolved over the last decade; the operative mortality has significantly reduced to <5%. A questionnaire was sent to 10 institutions based on their case volume. Questionnaire was based on: (1) preoperative biliary drainage, (2) bile replacement, (3) role of synbiotics, (4) remnant liver volume enhancement, (5) predicted remnant liver function, (6) imaging, (7) nutrition, and(8) role of Inchinkoto. The median case volume was 226 (range105-889) cases, respectively. Eight institutions preferred endoscopic nasobiliary drainage and two preferred endoscopic biliary stenting for biliary drainage. Nine used bile replacement within 2-3days of biliary drainage. Four used synbiotics preoperatively. The median cutoff value for future remnant liver volume and serum totalbilirubin, at which portal vein embolization (PVE) is done, is <40% and <4mg/dl. The median interval between PVE and surgery was 3-4weeks. To predict remnant liver function, indocyanine green retention (n=8) and clearance rate (n=2) were mainly used. Five used Inchinkoto to improve liver function. Nine used multidetector computed tomography and direct cholangiography for surgical planning. With appropriate preoperative management of PHC, surgical morbidity and mortality can be reduced. This survey can provide recommendations to improve PHC perioperative outcomes.