Preoperative biliary drainage in resectable perihilar cholangiocarcinoma: real-world burden.

BACKGROUND: Preoperative biliary drainage (PBD) in perihilar cholangiocarcinoma (pCCA) remains challenging, and its burden among patients who ultimately do not undergo curative-intent surgery is uncertain. We characterized the PBD pathway and identify factors associated with failure of curative-intent management. RESEARCH DESIGN AND METHODS: This retrospective, single-center cohort study included 109 patients with initially resectable pCCA requiring PBD at a tertiary hepatobiliary center between 2010 and 2025. Drainage sequences, complications, surgical and oncological outcomes, and factors associated with surgical exclusion or 90-day mortality were assessed. RESULTS: Resection was achieved in 84 patients (77.1%). Repeated drainage increased septic morbidity (83.1% vs 62.0%, p = 0.013). Pancreatitis with a CT Severity Index ≥ 4 or severe acute pancreatitis was associated with surgical exclusion (50.0% vs 20.2%, p = 0.048). Drainage-related septic complications independently predicted impaired disease-free survival (HR 3.69, 95%CI 1.58-8.59, p = 0.002). A 7-point score including age > 70 years, arterial hypertension, post-drainage pancreatitis, and post-drainage septic complications predicted surgical exclusion or 90-day mortality (AUC 0.766). CONCLUSIONS: PBD carries substantial morbidity and may compromise the curative pathway for resectable pCCA. Early expert referral and planned first-attempt drainage are essential. Optimal management of the PBD period before surgery may help to reduce the burden of the surgical resection.