Survey of preoperative management protocol for perihilar cholangiocarcinoma at 10 Japanese high-volume centers with a combined experience of 2,778 cases.

Background: In Japan, strategies for preoperative management of perihilar cholangiocarcinoma (PHC) have evolved over the last decade; the operative mortality has significantly reduced to <5%.

Methods: A questionnaire was sent to 10 institutions based on their case volume. Questionnaire was based on: (1) preoperative biliary drainage, (2) bile replacement, (3) role of synbiotics, (4) remnant liver volume enhancement, (5) predicted remnant liver function, (6) imaging, (7) nutrition, and (8) role of Inchinkoto.

Results: The median case volume was 226 (range 105-889) cases, respectively. Eight institutions preferred endoscopic nasobiliary drainage and two preferred endoscopic biliary stenting for biliary drainage. Nine used bile replacement within 2-3 days of biliary drainage. Four used synbiotics preoperatively. The median cutoff value for future remnant liver volume and serum total bilirubin, at which portal vein embolization (PVE) is done, is <40% and <4 mg/dl. The median interval between PVE and surgery was 3-4 weeks. To predict remnant liver function, indocyanine green retention (n = 8) and clearance rate (n = 2) were mainly used. Five used Inchinkoto to improve liver function. Nine used multidetector computed tomography and direct cholangiography for surgical planning.

Conclusion: With appropriate preoperative management of PHC, surgical morbidity and mortality can be reduced. This survey can provide recommendations to improve PHC perioperative outcomes.