Preoperative Stenting for Benign and Malignant Periampullary Diseases: Unnecessary if Not Harmful

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Key points

  • •

    Preoperative biliary drainage (PBD) is often performed in patients with jaundice with the presumption that it will decrease the risk of postoperative complications.

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    PBD carries its own risk of complications and, therefore, has been controversial.

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    Multiple randomized controlled trials and metaanalyses have shown that PBD has significantly increased overall complications compared with surgery alone.

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    The routine application of PBD should be avoided except in a subset of clinical situations.

The problem: increased infectious complications with preoperative biliary drainage

PBD before pancreaticoduodenectomy leads to colonization of sterile bile and consequently increases risk of infections, including surgical site infection, cholangitis, and sepsis. Numerous studies have shown that subjects undergoing PBD have higher rates of positive intraoperative bile cultures and carry higher infectious-related morbidity and mortality. In an early study from the authors’ institution, Povoski and colleagues12 reviewed 161 subjects who underwent pancreaticoduodenectomy with

Randomized Controlled Trials

Six randomized controlled trials (RCTs) failed to show any significant clinical benefit from routine stenting and demonstrated increased postoperative complications and poor outcome. The presumed benefits of PBD are largely theoretic.

The best designed multicenter RCT, from the Netherlands, examined 202 subjects with periampullary tumors and obstructive jaundice (bilirubin level 2.3–14.6 mg/dL) who were randomized to PBD for 4 to 6 weeks versus surgery alone within 1 week of study enrollment.13

Effects on preoperative biliary drainage on survival

Whether PBD and the associated delay in surgery in patients with malignant pancreatic head tumors affects survival was evaluated in a multicenter trial by Eshuis and colleagues.27 Subjects with a bilirubin of 2 to 14 mg/dL were randomized into drainage group (PBD) for 4 to 6 weeks or to proceed with early surgery (ES; <1 week). The investigators found that PBD and the associated delay in surgery did not affect overall survival compared with early surgery. The median survival times were

Plastic versus metal stents

In patients with unresectable pancreatic head tumors, metal stents are superior and preferred compared with plastic stents, whether the same is true for patients with resectable tumors when early surgery is not feasible remains an area of controversy. An attempt to answer this question was made by Crippa and colleagues28 in a metaanalysis of 5 studies, including 1 prospective trial29 and 4 retrospective studies,30, 31, 32, 33 with a total of 704 subjects (Table 4). The investigators evaluated

Costs of preoperative biliary drainage

Given the increased complication rate and morbidity associated with PBD, a British group evaluated the economic implications of PBD versus direct surgery for subjects with obstructive jaundice.34 In their model, the investigators estimated the mean costs and quality-adjusted life years per patient in the UK National Health Service over 6 months and demonstrated that PBD was more costly than surgery alone (mean cost per patient $15,616 compared with $11,914). They reported fewer quality-adjusted

Indications for preoperative stenting for selected clinical situation

There are several clinical circumstances in which the authors think that PBD could be beneficial. First, one should consider PBD in patients with debilitating pruritus or in cases when further extended workup is needed or a surgical intervention cannot be scheduled in a timely fashion for logistical reasons. Another group of patients in whom PBD is recommended is those who present with signs of systemic infections, such as cholangitis, and require emergent decompression. PBD is typically

Summary and authors’ recommendations

The authors do not recommend routine PBD in asymptomatic jaundiced patients with benign or malignant periampullary tumors before resection. We prefer selective PBD for patients with long-standing jaundice or cholangitis, renal impairment, severe malnutrition, neoadjuvant chemotherapy, debilitating pruritus affecting quality of life, or any special circumstance that delays a surgical procedure. We prefer the endoscopic approach for biliary drainage for periampullary tumors. Percutaneous

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    • Cited by (11)

    • INR and not bilirubin levels predict postoperative morbidity in patients with malignant obstructive jaundice

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      Once PBD is present operation should be performed at least after 4 weeks to decrease the risk of severe postoperative complications with no fear of disease progress. Routine PBD should be avoided in light of increased postoperative complications, and the indication for PBD placement should be drawn on an individual basis for each patient.20,21 The Results of this study are in considerable concordance with recent studies, concerning the question of PBD versus upfront surgery in regard of postoperative outcome.1,10,11,22–26

    • A novel nomogram for predicting the risk of major complications after pancreaticoduodenectomy in patients with obstructive jaundice

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      If PBD is unnecessary for those patients, then this intervention should be avoided. This result was consistent with those of previous studies [18,19]. Second, ERCP might be a better selection as the method of PBD.

    • Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis

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      As revealed in this study, we could not find any preoperative factors lowering the incidence of cholangitis. Although preoperative biliary drainage tends to reduce the rate of cholangitis, there is substantial evidence for increased risk of severe complications following preoperative biliary drainage in hepatobiliary and pancreatic surgery [52–54]. Gaag et al. revealed preoperative biliary drainage to be associated with a high complication rate of 46% for patients undergoing surgery for pancreatic cancer [52].

    • Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

      2020, Pancreatology
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      Recent researches have shown that routine PBD cannot reduce morbidity and mortality compared to surgery alone, even adversely affects surgical outcomes [4–8]. Furthermore, PBD has its own risk of complications such as acute cholangitis related to the operation, acute pancreatitis, duodenal perforation, failure of the operation, and stent dysfunction [9–11]. A high-quality multicenter randomized trial has demonstrated that routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications.

    • Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge

      2023, Cancers

    • Surgery for periampullary pancreatic cancer

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    This study was supported in part by NIH/NCI P30 CA008748 (Cancer Center Support Grant).

    Disclosure Statement: The authors have nothing to disclose.

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