title: Simultaneous biliary drainage and portal vein embolization before extended hepatectomy for hilar cholangiocarcinoma: preliminary experience.
abstract: BACKGROUND
  Patients with resectable hilar cholangiocarcinoma often present obstructive jaundice and a small future remnant liver (FRL) ratio. A sequential approach comprising preoperative biliary drainage followed by portal vein embolization (PVE) is usually performed but leads to long preoperative management (6-12 weeks) before patients can undergo resection. To simplify and shorten this phase of liver preparation, we developed a new preoperative approach that involves percutaneous biliary drainage and PVE during the same procedure. We report the outcomes of this combined procedure.
  
  
  METHODS
  During 1 year, four patients underwent simultaneous biliary drainage and PVE followed 1 month later by surgical resection of hilar cholangiocarcinoma. Liver volumes were assessed by CT before, and 1, and 3 months after the combined procedure. Serum liver enzymes were assessed before and 1 month after the combined procedure.
  
  
  RESULTS
  The combined procedure was feasible in all cases, with no related complications. After the combined procedure, transaminases remained stable or decreased, whereas gamma-glutamyl-transpeptidase, alkaline phosphatase, and bilirubin decreased. During the first month, the left lobe volume increased by +27.9 % (range 19-40.9 %). The FRL ratio increased from 24.9 to 33.2 %. All patients underwent R0 liver resection with a favorable postoperative outcome. The remnant liver volume increased by +132 % (range 78-245 %) between 1 and 3 months.
  
  
  CONCLUSIONS
  Simultaneous percutaneous biliary drainage and PVE is feasible. This all-in-one preoperative approach greatly decreases waiting time until surgical resection. These encouraging results warrant further investigation to confirm the safety and to evaluate the reduction in the dropout rate for liver resection in this tumor with poor prognosis.
authors.affiliation: Digestive & Oncologic Imaging and Interventional Radiology unit, Department of Radiology and Interventional Radiology, CHUV University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland, boris.guiu@chu-dijon.fr.
authors.forename: Boris
authors.initials: B
authors.lastname: Guiu
authors.forename: Pierre
authors.initials: P
authors.lastname: Bize
authors.forename: Nicolas
authors.initials: N
authors.lastname: Demartines
authors.forename: Mickaël
authors.initials: M
authors.lastname: Lesurtel
authors.forename: Alban
authors.initials: A
authors.lastname: Denys
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D004322:Drainage; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D011169:Portal Vein; D011677:Punctures; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome