title: Preoperative biliary drainage for biliary tract and ampullary carcinomas.
abstract: We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for post-drainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Nagino
authors.forename: Tadahiro
authors.initials: T
authors.lastname: Takada
authors.forename: Masaru
authors.initials: M
authors.lastname: Miyazaki
authors.forename: Shuichi
authors.initials: S
authors.lastname: Miyakawa
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Tsukada
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kondo
authors.forename: Junji
authors.initials: J
authors.lastname: Furuse
authors.forename: Hiroya
authors.initials: H
authors.lastname: Saito
authors.forename: Toshio
authors.initials: T
authors.lastname: Tsuyuguchi
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Yoshikawa
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Ohta
authors.forename: Fumio
authors.initials: F
authors.lastname: Kimura
authors.forename: Takehiro
authors.initials: T
authors.lastname: Ohta
authors.forename: Hideyuki
authors.initials: H
authors.lastname: Yoshitomi
authors.forename: Satoshi
authors.initials: S
authors.lastname: Nozawa
authors.forename: Masahiro
authors.initials: M
authors.lastname: Yoshida
authors.forename: Keita
authors.initials: K
authors.lastname: Wada
authors.forename: Hodaka
authors.initials: H
authors.lastname: Amano
authors.forename: Fumihiko
authors.initials: F
authors.lastname: Miura
mesh_terms: D014670:Ampulla of Vater; D001661:Biliary Tract Neoplasms / Q000628:therapy*; D002277:Carcinoma / Q000628:therapy*; D004322:Drainage / Q000009:adverse effects / Q000379:methods*; D019317:Evidence-Based Medicine / Q000379:methods; D006801:Humans; D007564:Japan; D011300:Preoperative Care