title: Bismuth classification is associated with the requirement for multiple biliary drainage in preoperative patients with malignant perihilar biliary stricture.
abstract: BACKGROUND
  Single preoperative biliary drainage for malignant perihilar biliary stricture occasionally fails to control jaundice and cholangitis. Multiple biliary drainage is required in such cases, but their clinical background is unclear. We determined the clinical characteristics associated with the requirement for multiple biliary drainage.
  
  
  METHODS
  The consecutive 122 patients with malignant perihilar biliary stricture were enrolled in a single-center retrospective study. Preoperative biliary drainage was initially performed on the future remnant hepatic lobe. Additional drainage was performed if jaundice failed to improve or cholangitis developed in undrained hepatic lobes. Detailed clinical characteristics and the number of preoperative biliary drainage procedures required before operation were analyzed.
  
  
  RESULTS
  Thirty-one patients (25.4%) initially underwent multiple biliary drainage. However, 69 (56.7%) required multiple biliary drainage by the time of the operation. In the univariate analysis, the initial serum bilirubin level, cholangitis, percutaneous portal vein embolization, history of inserted endoscopic biliary stenting, length of preoperative period, operative procedure, and Bismuth classification were significant factors. In the multivariate analysis using these factors, Bismuth classification was independently associated with the requirement for multiple biliary drainage. The number of patients who required multiple biliary drainage was higher in those with Bismuth-II (91.9%), Bismuth-IIIa (65.7%), and Bismuth-IV (92.9%) than in those with Bismuth-I (22.2%) and Bismuth-IIIb (18.2%).
  
  
  CONCLUSIONS
  Patients with Bismuth-II, Bismuth-IIIa, and Bismuth-IV are at higher risk for multiple biliary drainage. A strategy based on the Bismuth classification for performing preoperative biliary drainage is important for patients with malignant perihilar biliary stricture.
authors.affiliation: Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, Miyagi, Japan.
authors.forename: Shin
authors.initials: S
authors.lastname: Miura
authors.forename: Atsushi
authors.initials: A
authors.lastname: Kanno
authors.forename: Atsushi
authors.initials: A
authors.lastname: Masamune
authors.forename: Shin
authors.initials: S
authors.lastname: Hamada
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Takikawa
authors.forename: Eriko
authors.initials: E
authors.lastname: Nakano
authors.forename: Naoki
authors.initials: N
authors.lastname: Yoshida
authors.forename: Seiji
authors.initials: S
authors.lastname: Hongo
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Kikuta
authors.forename: Kiyoshi
authors.initials: K
authors.lastname: Kume
authors.forename: Morihisa
authors.initials: M
authors.lastname: Hirota
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Yoshida
authors.forename: Yu
authors.initials: Y
authors.lastname: Katayose
authors.forename: Michiaki
authors.initials: M
authors.lastname: Uuno
authors.forename: Tooru
authors.initials: T
authors.lastname: Shimosegawa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000473:pathology* / Q000601:surgery*; D018281:Cholangiocarcinoma / Q000473:pathology* / Q000601:surgery*; D002779:Cholestasis / Q000209:etiology / Q000601:surgery*; D004322:Drainage / Q000379:methods*; D005260:Female; D006801:Humans; D041781:Jaundice, Obstructive / Q000209:etiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies