TITLE PAGE
Title: Pre-operative percutaneous transhepatic biliary drainage in hilar cholangiocarcinoma; Benfits or risk ?
Authors: Nattha Wongwichit, MD
Affiliations:
1
Department of radiology, Faculty of Medicine, Khon Kaen University, Thailand
Corresponding authors:
Name:
Nattha Wongwichit
Address: Department of radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002,
Thailand
Telephone: +66-85-0089599
Fax:
e-Mail:
borbae@hotmail.com
Type of contribution:
Original research results
Running title:
-operative percutaneous transhepatic biliary drainage in hilar CHCA;
Benfits or risk?
Number of words in the abstract:
xxx
Number of words in the text:
x,xxx
Number of tables:
x
Number of figures:
x
1
ABSTRACT
Background: Aims to reduce the risk of post operative hepatic failure in jaundice patient with
hilar CHCA by pre-operative PTBD was proved in several journal. (1) But attempt to reduce other
post operative risk and mortality rate in the same group by pre-operative PTBD remain
controversy. (1) (2, 3)
Objective: To compare mortality rate and post operative risk between the pre operative PTBD
group and the non PTBD group in jaundice patients with hilar CHCA who undergo hepatectomy.
Methods: The retrospective study was perform by using the Database on CASCAP of the patients
with hilar CHCA who undergo hepatectomy in Jan 2006- Jan 2011. This study was comparing
between the group of pre operative PTBD and the non PTBD group. The severity of post
operative hepatic failure were clarified into grade A,B and C based on the international
study group of liver surgery grading of post hepatectomy liver failure. The hospitalized
mortality rate and other post operative risk were also analyzed. All risk ratio were estimated
using logistic regression .
Results: All cases of hilar CHCA patients of xxx who underwent hepatectomy, xx % were male,
xx % were female, with a mean age of xx  x years old (range: xx-xx). Rate of post operative
hepatic failure in all severity was xx (95%CI: xx - xx) and the hospitalized mortality rate was xx
(95%CI: x-x). The results of grade A,B and C were xx%, % and % respectively. The mortality rate
and risk of post operative hepatic failure for patients who underwent PTBD were significantly
lower than those who underwent hepatectomy alone (P = xx and p = xx respectively). However
the other risks ( bile leakage, abscess, wound infection) were significant higher in the PTBD
group.
Conclusions: Pre-operative PTBD can reduce rate of post operative hepatic failure and the
mortality rate in the jaundice patient with hilar CHCA. But other post operative complication still
happened, hence the pre operative PTBD should be considerated in individual.
Key words: retrospective study, cholangiocarcinoma, pre-operative PTBD, post-operative
hepatic failure.
2
INTRODUCTION

Hilar cholangiocarcinoma is an adrenocarcinoma of the extrahepatic bile duct involving
the left main hepatic duct, the right main hepatic duct, or their confluence. Bile duct
resection in combination with major hepatectomy is the standard treatment for hilar
cholangiocarcinoma. The morbidity and mortality of liver resection are significantly
higher in patients with obstructive jaundice than in patients with normal liver function.
Therefore, preoperative biliary drainage (PBD) has been widely performed to reverse
cholestasis-associated liver dysfunction

Aims to reduce the risk of post operative hepatic failure in jaundice patient with hilar
CHCA by pre-operative PTBD was proved in several journal. (1) But attempt to reduce
other post operative risk and mortality rate in the same group by pre-operative PTBD
remain controversy. (1) (2, 3)

This study compared mortality rate and post operative risk between the pre operative
PTBD group and the non PTBD group in jaundice patients with hilar CHCA who undergo
hepatectomy.
MATERIALS AND METHODS
Study design
The retrospective study was perform by using the Database on CASCAP of the patients
with hilar CHCA who undergo hepatectomy in Jan 2010- Jan 2015 in srinagarind hospital. This
study was comparing between the group of pre operative PTBD and the group of operative
hepatectomy alone. The morbidity included all post operative complication such as
hepatic failure, pneumonia, abdominal collection and bile leakage. The hospitalized
mortality rate was also analyzed.
Study outcome
While patients were followed routinely after hepatectomy, we review the effect of PTBD
on hospitalized postoperative outcomes. Hence, postoperative mortality was defined as death
prior to hospital discharge. All postoperative complications were defined as events that
lengthened hospital stay. Infectious complications were defined according to the study by ; these
were intraabdominal abscess, wound infection, cholangitis, sepsis and lung infection.
Noninfectious complications included liver failure, bile leak, anastomotic leak, abdominal
collection, gastrointestinal bleeding, abdominal bleeding, respiratory failure and renal failure.
The severity of post operative hepatic failure were clarified into grade A,B and C based
on the international study group of liver surgery grading of post hepatectomy liver failure
(table) over a period of 5 days .
Grading
Hepatic function
 INR
 Consciousness
A
B
C
< 1.5
None
1.5-1.9
confusion
>2.0
enchephalopathy
3
Statistical analysis
Data are presented as mean ± SD or median and interquartile range. The χ 2 test or
Fisher’s exact test or RxC table analysis was used to compare categorical variables, and the
Student’s t test or Mann-Whitney U test was used to compare continuous variables. A
statistically significant difference was defined as a P value < 0.05. The variables of statistical
significance during univariate analysis were included in a follow-up multivariate analysis, by
using the logistic regression test. The OR and 95%CI were also calculated for individual factors
in the multivariate analysis. All statistical analyses were performed with SPSS
RESULTS
Total cases of hilar CHCA underwent
hepatectomy
(N = 142,698)
PTBD
Non PTBD
Post hepatectomy complication

Mortality in hospital period
 Bile leakage
 Abdominal collection
 Hepatic failure
 other
Fig. 1. The inclusion flow chart
Demographic Characteristics
All cases of hilar CHCA patients of xxx who underwent hepatectomy, xx % were male, xx
% were female, with a mean age of xx  x years old (range: xx-xx). (Fig. 1).
and the other factors such as LFT to evaluated base line of hepatic function (Table 1).
Table 1. Demographic characteristics presented as percentage unless specified otherwise
All cases of hilar CHCA
Pre OP PTBD
Non pre OP PTBD
4
Sex
male
female
Age
<30
30-40
40-50
50-60
>60
LFT
TB
Alb
INR
Benefits of pre operative PTBD
The group of pre operative PTBD were xx % and the group of operative hepatectomy alone
were xx %. Rate of post operative hepatic failure in all severity was xx (95%CI: xx - xx) and the
hospitalized mortality rate was xx (95%CI: x-x). The results of grade A,B and C were xx%, % and
% respectively. The mortality rate and the risk of post operative hepatic failure for patients who
underwent PTBD were significantly lower than those who underwent hepatectomy alone (P = xx
and p = xx respectively).
Post OP outcome
mortality
Morbidity
 Intraabdominal
abscess
 Cholangiis
 Pneumonia
 Bile leakage
 Wound infection
 Sepsis
 GI bleeding
Pre OP PTBD
No PTBD
Hepatic failure
 A
 B
 C
Benefits for hepatic failure after hepatic resection
P Value
5
DISCUSSIONS
Explaining the findings
<copy narrative parts of the Results followed by explaining each important findings in turn , 5-10 references
needed here in this section where about half of them are the same as the one cited in the Introduction section of
the manuscript>
Strength of the study
<to be written>
Limitation of the study



Can selection bias distort the findings?
Can information bias distort the findings?
Can confounding bias distort the findings?
Conclusions
(copy from the Conclusion section of the abstract then add some)
Recommendations
<to be written>
Acknowledgements: This material is based upon the TNCs supported by the Human Resource for Health
Research and Development Office, Health System Research Institute, the International Health Planning and
Policy, and the Thailand Nursing and Midwifery Council. All contents of this material, including opinions,
findings, discussion and conclusions or recommendations, are those of the authors and do not necessarily reflect
the official view of the TNCs Steering Committee. The authors thank to ???.
Funds: This work was financially supported by ??? and the Human Resource for Health Research and
Development Office of Thailand.
REFERENCES
1.
El-Hanafy E. Pre-operative biliary drainage in hilar cholangiocarcinoma, benefits and risks,
single center experience. Hepato-gastroenterology. 2010 May-Jun;57(99-100):414-9. PubMed PMID:
20698200.
2.
Xiong JJ, Nunes QM, Huang W, Pathak S, Wei AL, Tan CL, et al. Preoperative biliary drainage
in patients with hilar cholangiocarcinoma undergoing major hepatectomy. World journal of
gastroenterology : WJG. 2013 Dec 14;19(46):8731-9. PubMed PMID: 24379593. Pubmed Central
PMCID: 3870521.
3.
Paik WH, Loganathan N, Hwang JH. Preoperative biliary drainage in hilar cholangiocarcinoma:
When and how? World journal of gastrointestinal endoscopy. 2014 Mar 16;6(3):68-73. PubMed
PMID: 24634710. Pubmed Central PMCID: 3952162.
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