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• Guidelines for the diagnosis and treatment of cholangiocarcinoma
  Tony CK Tham
  Published on: 7 November 2002

• Published on: 7 November 2002

  Guidelines for the diagnosis and treatment of cholangiocarcinoma

  • Tony CK Tham, Consultant Gastroenterologist
  • Other Contributors:
    • R. John Moorehead

  Dear Editor

  We read with interest the British Society of Gastroenterology guidelines for the diagnosis and treatment of cholangiocarcinoma (Gut 2002:51(Suppl VI): 1-9).

  The authors recommend that routine biliary drainage before assessing resectability or preoperatively should be avoided except in the context of acute cholangitis. They do not state the rationale for this approach. Presumably the a...

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  Dear Editor

  We read with interest the British Society of Gastroenterology guidelines for the diagnosis and treatment of cholangiocarcinoma (Gut 2002:51(Suppl VI): 1-9).

  The authors recommend that routine biliary drainage before assessing resectability or preoperatively should be avoided except in the context of acute cholangitis. They do not state the rationale for this approach. Presumably the argument against preoperative biliary drainage is the possible increased risk for perioperative complications, increased risk of bile leakage of chole-enteric anastomosis because of stent-induced inflammatory response or increased mortality. On the other hand, the argument for preoperative biliary drainage is equally persuasive. There may be improvement in nutritional and metabolic function, including restoration of enterohepatic circulation and improvement in hepatic synthetic function and coagulation; improvement in immune function, reduced risk for perioperative complications or reduced mortality. The authors quote two studies to support their recommendation (Nakeeb et al., Hochwald et al.[1,2]). However they ignore two other prospective randomized controlled trials comparing preoperative biliary drainage with no preoperative biliary drainage (Lai et al.; Lygidakis et al.[3,4]). Lai et al.[3] revealed no difference in morbidity and mortality while Lygidakis et al.[4] found that there was significantly reduced operative morbidity and mortality with preoperative biliary drainage. They also ignore at least eight retrospective studies comparing preoperative biliary drainage with no preoperative biliary drainage which have conflicting results. These individual studies are flawed by the heterogeneous nature of the patients included; whether a sphincterotomy was performed alone or in combination with stent; insufficient sample sizes and varying types of surgical procedures used. A recent meta-analysis of these prospective and retrospective studies found no evidence of either a positive or adverse effect of preoperative endoscopic biliary stent placement on the outcome of surgery (Saleh et al.[5]). We therefore feel that there is insufficently robust data to justify the recommendation by the guidelines that preoperative biliary drainage or before assessing resectability should be avoided. In practice, because of the delay in the work up of a patient for resectability and especially with the limited resources of the NHS, there is a danger that these patients may develop complications from their obstructed biliary system in the interim. The recommendations are not based on level A evidence but are in fact level D evidence.

  In the algorithm for the management of cholangiocarcinoma, the authors state that if the lesion is resectable, patients should not have ERCP (unless infected) or percutaneous biopsy of the lesion. The implication is that patients will undergo major surgery which has a significant risk of mortality and morbidity without any prior attempt to obtain histology and therefore a definitive diagnosis. Discrimination of malignant from benign bile duct strictures is difficult although benign strictures are rare. However, up to 10% of bile duct strictures may turn out to be benign and may not be distinguishable from a malignant stricture even at surgery (Nakayama, et al.[6]). In summary, there is insufficient evidence to justify the recommendation that routine biliary drainage prior to resection or assessment for resection should be avoided. With the present data available, there is neither a positive or adverse effect of preoperative endoscopic biliary stent placement on the outcome of surgery. We also feel that prior to resection, attempts should be made to obtain histological confirmation with ERCP and brushings for cytology. If not, patients should be made aware that they may undergo resection for benign disease.

  References

  (1) Nakeeb A, Pitt HA. The role of preoperative biliary decompression in obstructive jaundice. Hepatogastroenterol 1995;42:332-7.

  (2) Hochwald SN, Burke EC, Jarnagin WR, et al. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 1999;134:261-6.

  (3) Lai ECS, Mok FPT, Fan ST, Lo CM, Chu KM, Liu CL, et al. Preooperative endoscopc drainage for malignant obstructive jaundice. Br J Surg 1994;81:1195-8.

  (4) Lygidakis NJ, van der Heyde MN, Lubbers MJ. Evaluation of preoperative biliary drainage in the surgical management of pancreatic head ccarcinoma. Acta Chir Scand 1987;153:665-8.

  (5) Saleh MA, Norregaard P, Jorgensen HL, Andersen PK, Matzen P. Preoperative endoscopic stent placement before pancreaticododenoectomy: a meta-analysis of the effect on morbidity and mortality. Gastrointest Endosc 2002;56:529-34.

  (6) Nakayama A, Imamura H, Shimada R, Miyagawa S, Makuuchi M, Kawasaki S. Proximal bile duct stricture disguised as malignant neoplasm. Surgery 1999;125:514-21.

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  Conflict of Interest:
  None declared.

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