World J Surg (2013) 37:1743–1744 DOI 10.1007/s00268-013-1955-3
Catheter Tract Recurrence After Percutaneous Biliary Drainage for Hilar Cholangiocarcinoma Hiroshi Kawakami
Published online: 21 February 2013 Ó Socie´te´ Internationale de Chirurgie 2013
I read with interest the paper by Kang et al. [1] on the outcome of catheter tract recurrence after preoperative percutaneous transhepatic biliary drainage (PTBD) for hilar cholangiocarcinoma (HCA). They reported PTBD catheter tract recurrence in 2.6 % (6/232) of cases. Their incidence was similar to that reported by Hwang et al. [2] (1.7 %, 4/231) and lower than that reported by Takahashi et al. [3] (5.2 %, 23/445). Takahashi et al. [3] and Kang et al. [1] revealed that the prognosis of PTBD catheter tract recurrence is generally poor, even after resection. They also discussed the limitations of endoscopic nasobiliary drainage (ENBD) for selective drainage, the possibility of malfunction or local inflammation around the tumor, and patient suffering. Selective preoperative biliary drainage is a wellestablished technique for experienced pancreatobiliary endoscopists with improved devices. However, we do not understand the local inflammation around the tumor. Kang et al. [1] suggested that passage of the ENBD tube through the stricture causes infiltration around the drainage tube. However, I have never seen a surgical specimen exhibiting local inflammation around a tumor caused by the ENBD tube. I mainly use straight ENBD tubes. A pigtail catheter might have a higher risk of the distal tip sticking into the wall of the bile duct/liver parenchyma. Do they caution against the effect of the ENBD tube tip?
H. Kawakami (&) Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Japan e-mail:
[email protected]
In addition, Kang et al. [1] insisted that ENBD is theoretically inferior to endoscopic biliary stenting (internal drainage) in terms of patient symptoms. I agree that ENBD can cause pharyngeal discomfort and pain and might worsen nasal discharge. These symptoms might reduce the patient’s activities of daily life. Despite such disadvantages relative to PTBD, ENBD is still the safest technique. I reported the superiority of ENBD over endoscopic biliary stenting and PTBD [4]. PTBD can cause not only cancer dissemination as a ‘‘lethal’’ complication but also vascular injury, which requires conversion to a surgical procedure. Cancer dissemination associated with bile spillage during PTBD is an unavoidable complication, regardless of the physician’s expertise [4]. Takahashi et al. [3] and Kang et al. [1] reported that the prognosis of PTBD catheter tract recurrence is generally poor, even after resection. Therefore, the most important point regarding preoperative biliary drainage in a patient with HCA is to use a ‘‘nonlethal’’ technique. Based on our results [4] and other reports [2, 3], including the report by Kang et al. [1], I recommend ENBD for patients expected to undergo radical surgery for HCA. I understand that complete biliary drainage of segmental bile ducts is not always possible endoscopically, such as in patients with Bismuth-Corlette type III to IV tumors. Recently, however, Kawashima et al. [5] reported that unilateral ENBD of the future remnant lobe(s) had a high success rate, suggesting that it is a suitable, effective preoperative biliary drainage method for HCA, even in patients with Bismuth-Corlette type III to IV tumors. Therefore, preoperative PTBD should be performed only in selected cases or as an alternative procedure when ENBD is difficult. Conflict of interest The authors report no conflicts of interest and no financial support.
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References 1. Kang MJ, Choi YS, Jang JY et al (2012) Catheter tract recurrence after percutaneous biliary drainage for hilar cholangiocarcinoma. World J Surg 37(2):437–442. doi:10.1007/s00268-012-1844-1 2. Hwang S, Song GW, Ha TY et al (2012) Reappraisal of percutaneous transhepatic biliary drainage tract recurrence after resection of perihilar bile duct cancer. World J Surg 36:379–385. doi:10.1007/s00268-011-1364-4 3. Takahashi Y, Nagino M, Nishio H et al (2010) Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma. Br J Surg 97:1860–1866
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World J Surg (2013) 37:1743–1744 4. Kawakami H, Kuwatani M, Onodera M et al (2011) Endoscopic nasobiliary drainage is the most suitable preoperative biliary drainage method in the management of patients with hilar cholangiocarcinoma. J Gastroenterol 46:242–248 5. Kawashima H, Itoh A, Ohno E et al (2012) Preoperative endoscopic nasobiliary drainage in 164 consecutive patients with suspected perihilar cholangiocarcinoma: a retrospective study of efficacy and risk factors related to complications. Ann Surg 257(1):121–127
