title: Percutaneous vs. endoscopic pre-operative biliary drainage in hilar cholangiocarcinoma - a systematic review and meta-analysis.
abstract: The strategy for preoperative management of biliary obstruction in hilar cholangiocarcinoma (HCCA) patients with regards to drainage by endoscopic (EBD) or percutaneous (PTBD) methods is not clearly defined. The aim of this study was to investigate the utility, complications and therapeutic efficacy of these methods in HCCA patients, with a secondary aim to assess the use of portal vein embolization (PVE) in patients undergoing drainage.
  
  
  
  Studies incorporating HCCA patients undergoing biliary drainage prior to curative resection were included (EMBASE and Medline databases). Analyses included baseline drainage data, procedure-related complications and efficacy, post-operative parameters, and meta-analyses where applicable.
  
  
  
  Fifteen studies were included, with EBD performed in 536 patients (52%). Unilateral drainage of the future liver remnant was undertaken in 94% of patients. There was a trend towards higher procedure conversion (RR 7.36, p = 0.07) and cholangitis (RR 3.36, p = 0.15) rates in the EBD group. Where specified, 134 (30%) drained patients had PVE, in association with a major hepatectomy in 131 patients (98%). Post-operative hepatic failure occurred in 22 (11%) of EBD patients compared to 56 (13%) of PTBD patients, whilst median 1-year survival in these groups was 91% and 73%, respectively.
  
  
  
  The accepted practice is for most jaundiced HCCA patients to have preoperative drainage of the future liver remnant. EBD may be associated with more immediate procedure-related complications, although it is certainly not inferior compared to PTBD in the long term.
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia.
authors.forename: Ahmer
authors.initials: A
authors.lastname: Hameed
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia.
authors.forename: Tony
authors.initials: T
authors.lastname: Pang
authors.affiliation: Department of Medicine, Westmead Hospital, Sydney, Australia.
authors.forename: Judy
authors.initials: J
authors.lastname: Chiou
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia.
authors.forename: Henry
authors.initials: H
authors.lastname: Pleass
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia.
authors.forename: Vincent
authors.initials: V
authors.lastname: Lam
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Hollands
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia.
authors.forename: Emma
authors.initials: E
authors.lastname: Johnston
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia.
authors.forename: Arthur
authors.initials: A
authors.lastname: Richardson
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney, Australia; Discipline of Surgery, University of Sydney, Australia. Electronic address: lawrence.yuen@sydney.edu.au.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Yuen
mesh_terms: D001650:Bile Duct Neoplasms / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D002779:Cholestasis / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D004322:Drainage / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D004621:Embolization, Therapeutic / Q000379:methods; D004724:Endoscopy / Q000009:adverse effects / Q000401:mortality; D006498:Hepatectomy; D006801:Humans; D041781:Jaundice, Obstructive / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D018285:Klatskin Tumor / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016017:Odds Ratio; D011169:Portal Vein; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome