Preoperative biliary drainage

Obstructive jaundice, clinically evident by jaundiced skin, nausea, pruritus, dark urine and discoloration of stool, is the most prevalent presenting symptom of hilar cholangiocarcinoma (HCCA). Obstructive jaundice is associated with a proinflammatory state, resulting from portal and systemic endotoxemia, increased permeability of the intestinal mucosal barrier, an altered reticuloendothelial system function of Kupffer cells in the liver, and increased concentrations of proinflammatory cytokines [1-3]. The exact link between jaundice and the development of infectious complications remains yet to be elucidated, but jaundice has been largely recognized as a major risk factor for performing pancreatic and liver surgery [4-6]. The presence of toxic substances such as bilirubin and bile salts, impaired liver function, and altered nutritional status have been proposed as responsible factors for increased infectious complications.