Preoperative biliary drainage in patients with proximal bile duct
obstruction: Endoscopic or percutaneous approach?
JJ. Kloek1, NA. van der Gaag1, Y. Aziz1, OM. van Delden2, EAJ. Rauws3, ORC. Busch1,
DJ. Gouma1, TM. van Gulik1
(1) Department of Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
(2) Department of Radiology, Academic Medical Center, University of Amsterdam, The Netherlands
(3) Department of Gastroenterology, Academic Medical Center, University of Amsterdam, The Netherlands
INTRODUCTION: Obstructive jaundice is a significant risk factor in the treatment of patients with hilar
cholangiocarcinoma (HCCA) requiring major liver resection. Controversy exists over the preferred
technique of preoperative biliary drainage (PBD), either via the endoscopic route by retrograde
cholangiopancreaticography (ERCP) or using percutaneous transhepatic biliary drainage (PTBD),
while no randomized studies exist. The aim of this study was to compare complications and success
rate of ERCP and PTBD in patients eligible for resection of HCCA.
METHODS: A total of 102 patients underwent an explorative laparotomy on the suspicion of HCCA
between 2001 and 2008. Demographic features, tumor stage according to the Bismuth classification,
laboratory investigations and the results of radiological and endoscopic drainage interventions were
investigated. Patients who underwent either ERCP or PTBD as primary procedure were compared for
technical success, procedure related complications, mean number of procedures, duration of drainage
until laparotomy and the decrease in serum bilirubin level.
RESULTS: Of 102 patients 88 (87%) underwent PBD; 78 patients underwent ERCP as primary
procedure and 10 patients PTBD. Age, gender, tumor stage did not differ significantly between groups.
The technical success rate of initial stent insertion was 78% in the ERCP versus 100% in the PTBD
group (P=.20). Stent dislocation was similar in the ERCP and PTBD group (27% vs. 20%, P=.56),
whereas infectious complications were significantly more common in the endoscopic group (53% vs.
10%, P=.01). Patients in the ERCP group underwent significantly more drainage procedures (2.9 vs.
1.6, P<.01), of which 25 patients required a PTBD as final procedure. The drainage period until
laparotomy was 15 weeks (min-max 4-29) in the ERCP group vs. 10 (3-21) in the PTBD group (P=.09).
Success rate, defined as a decrease in serum bilirubin levels, was similar in both groups. A sub
analysis of the 25 patients undergoing both procedures showed most stent dislocations (48%) and
infectious complications (64%), resulting in a mean number of 4.3 (range 2 – 7) procedures per patient.
CONCLUSIONS: The present study shows in patients with suspicion on HCCA, lower infectious
complications after PTBD compared to ERCP, resulting in significantly less procedures. These results
suggest a more favourable outcome of percutaneous drainage, and underline the importance of
further (randomized) studies to be performed.