title: Preoperative biliary drainage in perihilar cholangiocarcinoma: identifying patients who require percutaneous drainage after failed endoscopic drainage.
abstract: OBJECTIVE
  Preoperative biliary drainage is often initiated with endoscopic retrograde cholangiopancreatography (ERCP) in patients with potentially resectable perihilar cholangiocarcinoma (PHC), but additional percutaneous transhepatic catheter (PTC) drainage is frequently required. This study aimed to develop and validate a prediction model to identify patients with a high risk of inadequate ERCP drainage.
  
  
  METHODS
  Patients with potentially resectable PHC and (attempted) preoperative ERCP drainage were included from two specialty center cohorts between 2001 and 2013. Indications for additional PTC drainage were failure to place an endoscopic stent, failure to relieve jaundice, cholangitis, or insufficient drainage of the future liver remnant. A prediction model was derived from the European cohort and externally validated in the USA cohort.
  
  
  RESULTS
  Of the 288 patients, 108 (38%) required additional preoperative PTC drainage after inadequate ERCP drainage. Independent risk factors for additional PTC drainage were proximal biliary obstruction on preoperative imaging (Bismuth 3 or 4) and predrainage total bilirubin level. The prediction model identified three subgroups: patients with low risk (7%), moderate risk (40%), and high risk (62%). The high-risk group consisted of patients with a total bilirubin level above 150 µmol/L and Bismuth 3a or 4 tumors, who typically require preoperative drainage of the angulated left bile ducts. The prediction model had good discrimination (area under the curve 0.74) and adequate calibration in the external validation cohort.
  
  
  CONCLUSIONS
  Selected patients with potentially resectable PHC have a high risk (62%) of inadequate preoperative ERCP drainage requiring additional PTC drainage. These patients might do better with initial PTC drainage instead of ERCP.
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Jimme K
authors.initials: JK
authors.lastname: Wiggers
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Bas
authors.initials: B
authors.lastname: Groot Koerkamp
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Coelen
authors.affiliation: Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Erik A
authors.initials: EA
authors.lastname: Rauws
authors.affiliation: Department of Gastroenterology, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schattner
authors.affiliation: Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: C Yung
authors.initials: CY
authors.lastname: Nio
authors.affiliation: Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Karen T
authors.initials: KT
authors.lastname: Brown
authors.affiliation: Department of Statistics, Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Mithat
authors.initials: M
authors.lastname: Gonen
authors.affiliation: Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Susan
authors.initials: S
authors.lastname: van Dieren
authors.affiliation: Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Krijn P
authors.initials: KP
authors.lastname: van Lienden
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Allen
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Marc G H
authors.initials: MG
authors.lastname: Besselink
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Olivier R C
authors.initials: OR
authors.lastname: Busch
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Michael I
authors.initials: MI
authors.lastname: D'Angelica
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Robert P
authors.initials: RP
authors.lastname: DeMatteo
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: T Peter
authors.initials: TP
authors.lastname: Kingham
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000473:pathology / Q000601:surgery; D001662:Biliary Tract Surgical Procedures / Q000009:adverse effects / Q000379:methods; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods; D002761:Cholangitis / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D002779:Cholestasis / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D004322:Drainage / Q000379:methods*; D005260:Female; D006801:Humans; D018285:Klatskin Tumor / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011300:Preoperative Care / Q000009:adverse effects / Q000379:methods; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D014481:United States