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Peer-reviewedCC BY 4.0Cancers

Biliary Drainage and Complex Hepatobiliary Surgery in Biliary Tract Cancers: A Framework for Selective Centralization

  • Dennis Björk1,2
  • Emine Selda Gündüz3
  • Piotr Kalinowski4
  • Giovanni Scotton5
  • Rocio I. R. Macias6,7
  • Elene Mariamidze8
  • Anna Saborowski9
  • Gonzalo Sapisochin10
  • Angela Lamarca11
11 affiliations
  1. 1Department of Biomedical and Clinical Sciences, Linköping University, 581 83 Linköping, Sweden
  2. 2Clinical Department of Surgery in Linköping, Region Östergötland, 581 83 Linköping, Sweden
  3. 3Department of Medical Services and Techniques, Vocational School of Health Services, Akdeniz University, Antalya 07070, Türkiye
  4. 4Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland
  5. 5Department of General and Visceral Surgery, Academic Hepatobiliary Center, Kepler University Hospital, 4021 Linz, Austria
  6. 6Experimental Hepatology and Drug Targeting (HEVEPHARM) Group, University of Salamanca, IBSAL, 37007 Salamanca, Spain
  7. 7Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
  8. 8Department of Oncology and Hematology, Todua Clinic, 0112 Tbilisi, Georgia
  9. 9Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, 30625 Hannover, Germany
  10. 10Department of Abdominal, General Surgery and Liver Transplantaion, Hepatobiliary and Liver Transplant Unit, Hospital Universitario Vall d’Hebron, CIRCATH Group, Vall d’Hebron Institute of Research (VHIR), 08035 Barcelona, Spain
  11. 11Department of Medical Oncology, OECI Comprehensive Cancer Centre—ENETS Centre of Excellence (GEP and Lung)—Fundacion Jimenez Diaz University Hospital, Health Research Institute Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), 28049 Madrid, Spain
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Abstract

Background/Objectives: Biliary tract cancers (BTCs) are rare, heterogeneous malignancies that frequently present with biliary obstruction and require complex multidisciplinary care. Decisions regarding biliary drainage, future liver remnant (FLR) optimization, and major hepatobiliary surgery may influence perioperative risk and treatment eligibility. This narrative review evaluates the evidence supporting selective centralization and proposes a network-based framework that considers tumor subtype, procedural complexity, and access to care. Methods: The scope and principal topics were defined during the multidisciplinary COST Training School “Biliary Tract Cancers: Practical Approaches in Challenging Environments”, held in Barcelona, Spain, on 20–21 March 2026. Members of the author group conducted topic-specific PubMed/MEDLINE searches within their areas of expertise. Guidelines, systematic reviews, meta-analyses, and relevant clinical studies were synthesized narratively. BTC-specific findings were distinguished from evidence derived from mixed populations. No formal risk-of-bias assessment or consensus voting process was undertaken. Results: Preoperative biliary drainage should be selective, with the indication, target, and modality determined by clinical status, biliary anatomy, treatment intent, and planned intervention. FLR assessment should integrate volume and function, particularly in patients with cholestasis or cholangitis. Evidence supporting augmentation strategies varies by technique and population. Observational studies associate higher procedural volumes with favorable outcomes, although patient selection and case-mix differences limit causal interpretation. Tumor-specific pathways distinguish perihilar, intrahepatic, and distal cholangiocarcinoma and gallbladder cancer. The proposed network combines expert-center coordination of complex interventions with regional care supported by shared protocols, defined responsibilities, escalation pathways, and outcome monitoring. Conclusions: Selective centralization offers an organizational approach to balancing specialist expertise with timely and equitable access. Prospective multicenter evaluation is needed to assess safety, treatment delays, access to curative therapy, patient-centered outcomes, and resource use before wider clinical or policy adoption.

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Cite

BibTeXRIS
BibTeX
@article{bjork2026biliary,
  title = {{Biliary Drainage and Complex Hepatobiliary Surgery in Biliary Tract Cancers: A Framework for Selective Centralization}},
  author = {Dennis Björk and Emine Selda Gündüz and Piotr Kalinowski and Giovanni Scotton and Rocio I. R. Macias and Elene Mariamidze and Anna Saborowski and Gonzalo Sapisochin and Angela Lamarca},
  journal = {Cancers},
  year = {2026},
  month = nov,
  doi = {10.3390/cancers18213572},
  url = {https://www.mdpi.com/2072-6694/18/21/3572},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Biliary Drainage and Complex Hepatobiliary Surgery in Biliary Tract Cancers: A Framework for Selective Centralization
AU  - Dennis Björk
AU  - Emine Selda Gündüz
AU  - Piotr Kalinowski
AU  - Giovanni Scotton
AU  - Rocio I. R. Macias
AU  - Elene Mariamidze
AU  - Anna Saborowski
AU  - Gonzalo Sapisochin
AU  - Angela Lamarca
PY  - 2026
DA  - 2026/11/06
JO  - Cancers
DO  - 10.3390/cancers18213572
UR  - https://www.mdpi.com/2072-6694/18/21/3572
AB  - Background/Objectives: Biliary tract cancers (BTCs) are rare, heterogeneous malignancies that frequently present with biliary obstruction and require complex multidisciplinary care. Decisions regarding biliary drainage, future liver remnant (FLR) optimization, and major hepatobiliary surgery may influence perioperative risk and treatment eligibility. This narrative review evaluates the evidence supporting selective centralization and proposes a network-based framework that considers tumor subtype, procedural complexity, and access to care. Methods: The scope and principal topics were defined during the multidisciplinary COST Training School “Biliary Tract Cancers: Practical Approaches in Challenging Environments”, held in Barcelona, Spain, on 20–21 March 2026. Members of the author group conducted topic-specific PubMed/MEDLINE searches within their areas of expertise. Guidelines, systematic reviews, meta-analyses, and relevant clinical studies were synthesized narratively. BTC-specific findings were distinguished from evidence derived from mixed populations. No formal risk-of-bias assessment or consensus voting process was undertaken. Results: Preoperative biliary drainage should be selective, with the indication, target, and modality determined by clinical status, biliary anatomy, treatment intent, and planned intervention. FLR assessment should integrate volume and function, particularly in patients with cholestasis or cholangitis. Evidence supporting augmentation strategies varies by technique and population. Observational studies associate higher procedural volumes with favorable outcomes, although patient selection and case-mix differences limit causal interpretation. Tumor-specific pathways distinguish perihilar, intrahepatic, and distal cholangiocarcinoma and gallbladder cancer. The proposed network combines expert-center coordination of complex interventions with regional care supported by shared protocols, defined responsibilities, escalation pathways, and outcome monitoring. Conclusions: Selective centralization offers an organizational approach to balancing specialist expertise with timely and equitable access. Prospective multicenter evaluation is needed to assess safety, treatment delays, access to curative therapy, patient-centered outcomes, and resource use before wider clinical or policy adoption.
SN  - 2072-6694
ER  -