Preoperative biliary drainage versus direct surgery for perihilar cholangiocarcinoma: A retrospective study at a single center.

Perihilar cholangiocarcinoma (pCC, also known as a Klatskin tumor) is the most common type of cholangiocarcinoma (CC). Preoperative biliary drainage (PBD) is indicated for pCC patients with acute cholangitis or patients who need portal vein embolization (PVE). However, the routine performance of PBD in other patients with pCC is still controversial. The current study retrospectively examined patients with pCC who did not undergo PVE and who did not have cholangitis who were seen at this Hospital to assess the advantages and disadvantages of PBD. This study also sought to find an optimal value of total bilirubin (TB) to indicate performing PBD. Between 2009 and 2014, after excluding patients with acute cholangitis and PVE, patients who had undergone hepatectomy for pCC were enrolled in this study. First, the surgical outcomes and postoperative outcomes were compared between PBD group and direct surgery group. Second, ROC curve analysis of a subgroup of patients was performed to find the best cut off value of TB for indicating the PBD. Third, the costs for patients, including the total charges and the charges per day were compared between the two groups. Subjects were 218 patients in total. Fifty-five patients underwent PBD. This group had a longer operative time [390 (210-700) vs. 360 (105-730) min, p = 0.013], and a longer hospital stay [20 (9-48) vs. 17 (6-93) days, p = 0.007], but underwent vascular resection and reconstruction less often [8 (14.5%) vs. 50 (30.7%), p = 0.019]. Mortality and morbidity were comparable between the two groups. ROC curve analysis of a subgroup of patients indicated that the cut-off value for total bilirubin was 218.75 μmol/L (12.4 mg/dL). The total hospital charges and the charges per day did not differ significantly for the two groups. Disadvantages of PBD were a longer operating time and a longer duration of hospitalization, but the short-term surgical outcomes and hospital charges of PBD group were comparable to the direct surgery group. PBD should be considered for patients when the diagnosis is still suspicious of pCC. Based on the current data, the optimal cut-off value for preoperative TB was 218.75 μmol/L (12.4 mg/dL) to indicate PBD for patients with pCC.