Preoperative biliary drainage in perihilar cholangiocarcinoma: retrospective multicentre analysis

BACKGROUND: There is no consensus on the use of preoperative biliary drainage for resectable perihilar cholangiocarcinoma. This retrospective cohort study aimed to explore the association of biliary drainage with postoperative mortality and morbidity. METHODS: This retrospective observational cohort study included patients who underwent resection of histologically confirmed perihilar cholangiocarcinoma from the Perihilar Cholangiocarcinoma Collaboration Group database across 27 Western hepatobiliary centres (2000-2022). To correct for baseline differences between patients who did or did not undergo drainage, propensity score weighting was applied. Outcomes were compared using propensity score-weighted regression and multivariable analysis. RESULTS: Overall, 2067 patients were included, of whom 350 (16.9%) did not undergo biliary drainage. Before propensity score weighting, patients who did not undergo drainage were less likely to have Bismuth III-IV disease (297 (78.9%) versus 1448 (84.3%); P < 0.001), had lower median bilirubin levels (12.0 versus 85.5 µmol/l; P < 0.001), and a higher proportion had left hepatectomies (150 (42.9%) versus 454 (26.4%); P < 0.001). After propensity score-weighted regression analysis, patients in the drainage group were more likely to experience major postoperative complications (odds ratio 1.43, 95% confidence interval 1.04 to 1.95; P = 0.027) and posthepatectomy liver failure (odds ratio 2.12, 1.25 to 3.58; P = 0.005). In multivariable analysis, only posthepatectomy liver failure remained significant (odds ratio 2.13, 1.29 to 3.54; P = 0.003). CONCLUSION: In this retrospective propensity score weighting analysis, preoperative biliary drainage was associated with a higher incidence of posthepatectomy liver failure in resectable perihilar cholangiocarcinoma. These findings suggest that a subgroup of patients with perihilar cholangiocarcinoma can be operated safely without biliary drainage. The indication for preoperative biliary drainage should be considered on an individual basis.