Selective Use of Biliary Drainage Supported in pCCA : BJS | Jun 2026

Introduction:

Preoperative biliary drainage (PBD) is frequently used in patients with perihilar cholangiocarcinoma (pCCA) to relieve biliary obstruction before surgery. The proposed benefits include improved liver function, reduced jaundice, and optimization of the future liver remnant before major hepatectomy. However, biliary drainage is also associated with procedure-related complications, infection, and potential delays to definitive surgery. As a result, its routine use remains controversial.

Problem Statement:

Current practice varies widely because there is no clear consensus regarding which patients with resectable pCCA truly benefit from preoperative biliary drainage. Determining whether drainage improves or worsens postoperative outcomes is critical for optimizing perioperative management and reducing surgical risk.

Summary:

This large international multicenter study evaluated the impact of preoperative biliary drainage on postoperative outcomes in patients undergoing resection for perihilar cholangiocarcinoma. After adjustment for important baseline differences, the investigators found that patients who underwent biliary drainage experienced higher rates of major postoperative complications and, most notably, a significantly increased risk of posthepatectomy liver failure. When additional multivariable analyses were performed, the association with posthepatectomy liver failure remained robust, suggesting that biliary drainage may contribute to adverse postoperative liver-related outcomes in selected patients. These findings challenge the traditional assumption that preoperative drainage is universally beneficial before major liver resection for pCCA. Importantly, the study does not imply that biliary drainage should be abandoned altogether. Rather, it highlights that a subset of patients with resectable disease may proceed safely to surgery without routine drainage. The results support a more individualized approach in which decisions are guided by factors such as bilirubin levels, cholangitis, anticipated future liver remnant volume, and planned extent of resection. Given the retrospective nature of the analysis, definitive conclusions regarding causality cannot be drawn. Nevertheless, this represents one of the largest studies addressing this question and provides important evidence that routine preoperative biliary drainage should be carefully reconsidered. Future prospective studies are needed to better define which patients derive genuine benefit from drainage before surgery for perihilar cholangiocarcinoma.