Preoperative biliary drainage before resection for hilar cholangiocarcinoma: whether or not? A systematic review.

backgroundThe value of preoperative biliary drainage (PBD) before resection for hilar cholangiocarcinoma (HCCA) is still controversial nowadays. The objective of this review is to summarize quantitatively the evidence related to this issue.

methodsTwo investigators independently searched the Medline, Embase, Academic Search Premier (EBSCO), Chinese BioMedical Literature on disc (CBMdisc), and Chinese Medical Current Contents (CMCC) databases. Eleven studies with a total number of 711 HCCA cases were included. Comparison was made of PBD versus no PBD in HCCA patients undergoing surgical resection. Outcome measures were postoperative complications, in-hospital death rate, postoperative infectious complications, and postoperative hospital stay.

resultsThere was no difference in death rate or postoperative hospital stay between the two treatment modalities. However, the overall postoperative complication rate and postoperative infectious complication rate were significantly adversely affected by PBD compared with surgery without PBD. In postoperative complications analysis, ten studies including 442 patients who underwent PBD and 233 patients who had no PBD were estimated. The odds ratio (OR) for postoperative morbidity was 1.67: 95% confidence interval (CI) [1.17, 2.39]. In postoperative mortality analysis, ten studies including 422 patients who underwent PBD and 238 patients who had no PBD were estimated. The OR for postoperative mortality was 0.70: 95% CI [0.41, 1.19]. In postoperative infectious complications analysis, five studies including 134 patients who underwent PBD and 122 patients who had no PBD were estimated. The OR for infectious morbidity was 2.17: 95% CI [1.24, 3.80]. In postoperative hospital stay analysis, only three studies with 84 patients who underwent PBD and 65 patients who had no PBD were estimated; the weighted mean difference (WMD) for postoperative hospital stay was 5.37 days: 95% CI [-1.78, 12.52 days].

conclusionsThis systematic review could not provide evidence for a clinical benefit of using PBD in jaundiced patients with HCCA planned for surgery. Preoperative drainage should not routinely be performed in patients with proximal bile duct cancer scheduled for surgical resection. Because of the lack of uniformity of this analysis, randomized controlled trials (RCTs) with large sample size and improved PBD techniques should be carried out to confirm our results.