title: Endoscopic or percutaneous biliary drainage for Klatskin tumors?
abstract: OBJECTIVE
  Controversy exists regarding the preferred biliary drainage technique in patients with Klatskin tumors because few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD).
  
  
  METHODS
  Consecutive patients (N = 129) with Klatskin tumors treated with initial EBD or PTBD were identified, and their clinical histories were retrospectively reviewed. The primary endpoint was the time to therapeutic success (TTS), defined as the time between the first drainage and a total bilirubin measurement of 40 μmol/L or lower.
  
  
  RESULTS
  EBD was the first biliary decompression procedure performed in 87 patients; PTBD was performed first in 42. Technical success rates (78% with EBD vs 98% with PTBD; P = .004) and therapeutic success rates (49% vs 79%, respectively; P = .002) were significantly lower in the EBD group than in the PTBD group. Forty-four patients in the EBD group (51%) subsequently underwent PTBD before therapeutic success was achieved or antitumoral treatment was started. Median TTSs were 61 days in the EBD group and 44 days in the PTBD group, and multivariate analysis showed a hazard ratio of 0.63 (95% confidence interval, 0.41-0.99; P = .045). In patients treated with surgery or chemotherapy with or without radiation therapy, median times to treatment were 76 and 68 days in the EBD and PTBD groups, respectively (P = .76). Cholangitis occurred in 25% and 21% of patients in the EBD and PTBD groups, respectively (P = .34).
  
  
  CONCLUSIONS
  PTBD should be seriously considered for biliary decompression when treating patients with Klatskin tumor.
authors.affiliation: Division of Medical Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada. thomas.walter@chu-lyon.fr
authors.forename: Thomas
authors.initials: T
authors.lastname: Walter
authors.forename: Chia S
authors.initials: CS
authors.lastname: Ho
authors.forename: Anne M
authors.initials: AM
authors.lastname: Horgan
authors.forename: Andrew
authors.initials: A
authors.lastname: Warkentin
authors.forename: Steve
authors.initials: S
authors.lastname: Gallinger
authors.forename: Paul D
authors.initials: PD
authors.lastname: Greig
authors.forename: Paul
authors.initials: P
authors.lastname: Kortan
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Knox
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000401:mortality* / Q000601:surgery*; D004322:Drainage / Q000401:mortality*; D016145:Endoscopy, Digestive System / Q000401:mortality*; D005260:Female; D006500:Hepatic Duct, Common / Q000601:surgery*; D006801:Humans; D018285:Klatskin Tumor / Q000401:mortality* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D011183:Postoperative Complications / Q000401:mortality; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome