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Ann Surg. Aug 1999; 230(2): 131.
PMCID: PMC1420854

Association of Preoperative Biliary Drainage With Postoperative Outcome Following Pancreaticoduodenectomy

Abstract

Objective

To determine whether preoperative biliary instrumentation and preoperative biliary drainage are associated with increased morbidity and mortality rates after pancreaticoduodenectomy.

Summary Background Data

Pancreaticoduodenectomy is accompanied by a considerable rate of postoperative complications and potential death. Controversy exists regarding the impact of preoperative biliary instrumentation and preoperative biliary drainage on morbidity and mortality rates after pancreaticoduodenectomy.

Methods

Two hundred forty consecutive cases of pancreaticoduodenectomy performed between January 1994 and January 1997 were analyzed. Multiple preoperative, intraoperative, and postoperative variables were examined. Pearson chi square analysis or Fisher’s exact test, when appropriate, was used for univariate comparison of all variables. Logistic regression was used for multivariate analysis.

Results

One hundred seventy-five patients (73%) underwent preoperative biliary instrumentation (endoscopic, percutaneous, or surgical instrumentation). One hundred twenty-six patients (53%) underwent preoperative biliary drainage (endoscopic stents, percutaneous drains/stents, or surgical drainage). The overall postoperative morbidity rate after pancreaticoduodenectomy was 48% (114/240). Infectious complications occurred in 34% (81/240) of patients. Intraabdominal abscess occurred in 14% (33/240) of patients. The postoperative mortality rate was 5% (12/240). Preoperative biliary drainage was determined to be the only statistically significant variable associated with complications (p = 0.025), infectious complications (p = 0.014), intraabdominal abscess (p = 0.022), and postoperative death (p = 0.037). Preoperative biliary instrumentation alone was not associated with complications, infectious complications, intraabdominal abscess, or postoperative death.

Conclusions

Preoperative biliary drainage, but not preoperative biliary instrumentation alone, is associated with increased morbidity and mortality rates in patients undergoing pancreaticoduodenectomy. This suggests that preoperative biliary drainage should be avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. Such a change in current preoperative management may improve patient outcome after pancreaticoduodenectomy.

Pancreaticoduodenectomy is accompanied by a considerable rate of postoperative complications and potential death. Despite advances in surgical techniques, intraoperative management, postoperative care, and a trend toward a decreasing rate of postoperative mortality, most large series still report postoperative morbidity rates in the range of 30% to 65%. 1–12 The exact contribution of specific preoperative, intraoperative, and postoperative variables to the development of postoperative death and complications remains uncertain.

In this regard, the routine use of biliary instrumentation by endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography and biliary drainage by endoscopic and percutaneous techniques in the preoperative evaluation of patients with potentially resectable pancreatic and peripancreatic lesions remains controversial. These instrumentation and drainage procedures of the biliary tract are themselves known to be associated with infectious complications. 13–43 However, relatively little information is available in the literature that specifically examines the effects of preoperative instrumentation and preoperative drainage of the biliary tract on morbidity and mortality rates after pancreaticoduodenectomy. A recent series of 74 selected, nonconsecutive pancreaticoduodenectomies performed within the confines of a nutritional trial at our institution demonstrated an association between preoperative biliary drainage and wound/intraabdominal complications when wound and intraabdominal complications were combined in the statistical analysis. 44 Therefore, the purpose of the present study was to determine more definitively whether preoperative biliary instrumentation and preoperative biliary drainage are associated with increased postoperative morbidity and mortality rates in a large series (n = 240) of consecutive pancreaticoduodenectomies.

PATIENTS AND METHODS

Between January 1994 and January 1997, 240 consecutive patients undergoing pancreaticoduodenectomy at Memorial Sloan-Kettering Cancer Center were identified from a prospectively collected database. By chart review, the following variables were retrospectively collected: age, sex, history of jaundice, history of diabetes mellitus, history of hypertension, history of coronary artery disease, history of cardiac arrhythmias, history of chronic obstructive pulmonary disease, history of cirrhosis, history of hepatitis, history of alcohol abuse, history of malignancies in the past, preoperative instrumentation, preoperative biliary drainage, history of preoperative pancreatic biopsy, history of fever and chills within 1 week of admission, preoperative total bilirubin level (mg/dl) on admission, pathologic diagnosis, type of pancreaticoduodenectomy performed, placement of intraoperative drain around the pancreaticojejunostomy or biliary–enteric anastomosis, placement of an intraoperative gastrostomy or feeding jejunostomy, surgical time, intraoperative blood loss, intraoperative transfusion of red blood cells, postoperative infectious complications (intraabdominal abscess [IAA], wound infection, urinary tract infection, bacteremia, pneumonia, catheter infection, Clostridium difficilediarrhea/colitis), other postoperative complications, postoperative hospital stay, and postoperative deaths.

Preoperative biliary instrumentation was defined as cannulation of the biliary tract by either nonsurgical and surgical techniques. This includes endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and surgical cannulation by common bile duct exploration. Preoperative biliary drainage was defined as creation of an artificial conduit between the biliary tract and the gastrointestinal tract or the exterior of the body by either surgical or nonsurgical techniques, regardless of whether a prosthetic device was used to form the artificial conduit. This includes endoscopically placed biliary stents, percutaneously placed external biliary drains, percutaneously placed internalized biliary stents, percutaneously placed cholecystostomy tubes, and surgical creation of an artificial conduit by T-tube choledochostomy, choledochojejunostomy, choledochoduodenostomy, or cholecystojejunostomy.

Postoperative IAA was suspected when there was persistent fever in the absence of wound, urinary, or pulmonary complications, or the development of unexplained clinical deterioration. Patients suspected of having an IAA underwent investigation by computed tomography (CT) of the abdomen and pelvis in an attempt to identify any localized intraabdominal collection of fluid and gas that was suggestive of an IAA. Pancreatic leak was defined by an elevated amylase level in fluid obtained from surgically placed pancreaticojejunostomy drain(s) or in fluid obtained from CT-guided or surgical intervention of all intraabdominal fluid collections. Bile leak was defined clinically or by an elevated bilirubin level in fluid obtained from surgically placed pancreaticojejunostomy drain(s) or in fluid obtained from CT-guided or surgical intervention of all intraabdominal fluid collections. Postoperative complication was defined as a complication occurring within 30 days after surgery or before discharge from the hospital. Postoperative death was defined as death within 30 days after surgery or before discharge from the hospital.

Results are expressed as the median (range) or the number and percentage of the total number of patients. The software program SPSS for Windows (version 8.0) from SPSS Inc. (Chicago, IL), was used for all statistical analyses. One-way analysis of variance was used to compare means of continuous variables. Univariate comparisons for all categorical variables were performed by Pearson chi square analysis with Yates’ correction for continuity (two-sided). When the expected frequency of one or more cells of a given 2 × 2 table for univariate comparison was ≤5, Fisher’s exact test (two-sided) was used. When multiple variables were determined to be statistically significant by univariate analysis, then all significant variables were entered into a logistic regression model for multivariate analysis to determine independent predictors of outcome. A probability value ≤0.05 was considered significant.

RESULTS

Demographics and Preoperative Variables

There were 240 patients who underwent a pancreaticoduodenectomy between January 1994 and January 1997. One hundred thirty-four patients (56%) were male and 106 (46%) were female. The median age was 66 years (range 6 to 87). One hundred sixty-six patients (69%) had a history of jaundice. Fifty-seven patients (24%) had a history of diabetes mellitus. Thirty-nine patients (16%) underwent preoperative pancreatic biopsy. Twenty-six patients (11%) had a history of fever and chills within 1 week of admission. The median preoperative total bilirubin level was 1.8 mg/dl (range 0.1 to 38.4) on admission.

Pathologic Diagnosis

Pancreaticoduodenectomy was performed for a variety of histopathologic diagnoses (Table 1). Eighty percent of patients (n = 190) had adenocarcinoma of the pancreas or peripancreatic region.

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Table 1. HISTOPATHOLOGY IN 240 PANCREATICODUODENECTOMIES

Preoperative Biliary Instrumentation and Drainage

One hundred seventy-five patients (73%) underwent preoperative biliary instrumentation (Table 2). A total of 243 preoperative biliary instrumentation procedures were performed. One hundred twenty-one patients underwent one biliary instrumentation procedure, 40 underwent two procedures, and 14 underwent three.

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Table 2. METHOD AND NUMBER (%) OF PREOPERATIVE BILIARY INSTRUMENTATION PROCEDURES PERFORMED IN 175 PATIENTS*

One hundred twenty-six patients (53%) underwent preoperative biliary drainage at the time of preoperative instrumentation (Table 3). A total of 156 preoperative biliary drainage procedures were performed. Ninety-nine patients underwent one biliary drainage procedure, 24 underwent two procedures, and 3 underwent three. One hundred biliary drainage procedures were performed at the time of the first biliary instrumentation procedure, 44 at the second, and 12 at the third. By univariate analysis, there was no significant difference in the general clinical characteristics and comorbid conditions (i.e., age, sex, history of diabetes mellitus, history of hypertension, history of coronary artery disease, history of cardiac arrhythmias, history of chronic obstructive pulmonary disease, history of cirrhosis, history of hepatitis, history of alcohol abuse, history of other malignancies in the past, history of preoperative pancreatic biopsy, and benign vs. malignant pancreatic/peripancreatic disease) that were present in the group of patients undergoing preoperative biliary drainage versus the group of patients not undergoing preoperative biliary drainage (Table 4).

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Table 3. METHOD AND NUMBER (%) OF PREOPERATIVE BILIARY DRAINAGE PROCEDURES PERFORMED AT THE TIME OF EACH PREOPERATIVE BILIARY INSTRUMENTATION IN 126 PATIENTS*
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Table 4. GENERAL CLINICAL CHARACTERISTICS AND COMORBID CONDITIONS

Pancreaticoduodenectomy and Intraoperative Variables

Two hundred nine patients (87%) underwent a standard pancreaticoduodenectomy, and 31 patients (13%) underwent a pylorus-preserving pancreaticoduodenectomy. Median total operating time was 330 minutes (range 175 to 995). One hundred thirty-seven patients (57%) underwent diagnostic laparoscopy before proceeding with pancreaticoduodenectomy. Median laparoscopy time was 35 minutes (range 7 to 122). Median intraoperative blood loss was 900 cc (range 100 to 4000). Median transfusion of red blood cells was 0 units (range 0 to 12). One hundred seventy-eight patients (74%) had a drain placed in proximity to the pancreaticojejunostomy or the biliary–enteric anastomosis at the time of pancreaticoduodenectomy. Sixty patients (25%) had a gastrostomy or feeding jejunostomy placed at the time of pancreaticoduodenectomy. Two hundred thirty-six patients (98%) received perioperative antibiotics.

Postoperative Complications

All postoperative complications are shown in Table 5. One or more postoperative complications occurred in 48% (114/240) of all patients. Postoperative infectious complications occurred in 34% (81/240) of all patients.

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Table 5. POSTOPERATIVE COMPLICATIONS IN 240 PANCREATICODUODENECTOMIES

Potential preoperative and intraoperative variables associated with postoperative complications were analyzed for all 240 patients by univariate analysis (Table 6). Preoperative biliary drainage was determined to be the only statistically significant variable associated with postoperative complications (p = 0.025). Neither the method of preoperative biliary drainage (nonsurgical vs. surgical, p = 0.999; endoscopic vs. percutaneous, p = 0.355) nor the number of preoperative biliary drainage procedures performed (one vs. two or more, p = 0.999) altered the association between preoperative biliary drainage and postoperative complications.

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Table 6. POTENTIAL PREOPERATIVE AND INTRAOPERATIVE VARIABLES ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS

Potential preoperative and intraoperative variables associated with postoperative infectious complications were analyzed by univariate analysis (Table 7). Preoperative biliary drainage was determined to be the only statistically significant variable associated with postoperative infectious complications (p = 0.014). Neither the method of preoperative biliary drainage (nonsurgical vs. surgical, p = 0.781; endoscopic vs. percutaneous, p = 0.345) nor the number of preoperative biliary drainage procedures performed (one vs. two or more, p = 0.875) altered the association between biliary drainage and postoperative infectious complications.

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Table 7. POTENTIAL PREOPERATIVE AND INTRAOPERATIVE VARIABLES ASSOCIATED WITH POSTOPERATIVE INFECTIOUS COMPLICATIONS

Intraabdominal abscess developed in 14% (33/240) of patients. Median time after surgery to diagnosis of IAA was 11 days (range 4 to 53). Thirty-two abscesses were diagnosed by CT of the abdomen, and one was diagnosed at autopsy. Potential preoperative and intraoperative variables associated with IAA were analyzed by univariate analysis (Table 8). Preoperative biliary drainage was determined to be the only statistically significant variable associated with IAA (p = 0.020). The finding of benign versus malignant disease approached statistical significance by univariate analysis (p = 0.066). Multivariate analysis of the significant and nearly significant variables by a logistic regression model disclosed preoperative biliary drainage (p = 0.022) as an independent predictor of IAA. Neither the method of preoperative biliary drainage (nonsurgical vs. surgical, p = 0.999; endoscopic vs. percutaneous, p = 0.446) nor the number of preoperative biliary drainage procedures performed (one vs. two or more, p = 0.782) altered the association between preoperative biliary drainage and IAA.

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Table 8. POTENTIAL PREOPERATIVE AND INTRAOPERATIVE VARIABLES ASSOCIATED WITH IAA

Postoperative Deaths

There were 12 postoperative deaths in 240 pancreaticoduodenectomies, yielding a postoperative mortality rate of 5%. The cause of death was IAA and sepsis in six patients (50%), myocardial infarction in two patients (17%), hepatic necrosis/failure in two patients (17%), colonic infarction in one patient (8%), and undetermined in one patient (8%). Median time to death after pancreaticoduodenectomy was 14 days (range 4 to 128). Potential preoperative and intraoperative variables associated with postoperative death were analyzed by univariate analysis (Table 9). Preoperative biliary drainage was determined to be the only statistically significant variable associated with postoperative death (p = 0.037). Neither the method of preoperative biliary drainage (nonsurgical vs. surgical, p = 0.339; endoscopic vs. percutaneous, p = 0.999) nor the number of preoperative biliary drainage procedures performed (one vs. two or more, p = 0.688) altered the association between biliary drainage and postoperative death.

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Table 9. POTENTIAL PREOPERATIVE AND INTRAOPERATIVE VARIABLES ASSOCIATED WITH POSTOPERATIVE DEATH

Potential postoperative complications associated with postoperative death were analyzed by univariate analysis (Table 10). Intraabdominal abscess and bacteremia were determined to be statistically significant postoperative complications associated with postoperative death. Multivariate analysis of the significant postoperative complications by a logistic regression model disclosed IAA (p = 0.011) and bacteremia (p = 0.023) as independent predictors of postoperative death.

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Table 10. POTENTIAL POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH POSTOPERATIVE DEATH

Subset Analysis of Adenocarcinoma of Pancreas and Peripancreatic Region

Potential preoperative and intraoperative variables associated with postoperative complications, infectious complications, IAA, and death within the subset of 190 patients with pancreatic and peripancreatic adenocarcinoma undergoing pancreaticoduodenectomies were analyzed by univariate and multivariate analyses (Table 11). No preoperative or intraoperative variables were determined to be statistically significantly associated with postoperative complications by univariate analysis. Preoperative biliary drainage (p = 0.038) and preoperative biliary instrumentation (p = 0.051) were determined to be statistically significant variables associated with infectious complications by univariate analysis. Multivariate analysis by a logistic regression model of these two variables determined to be significant by univariate analysis disclosed that only preoperative biliary drainage (p = 0.027) was an independent predictor of infectious complications. Preoperative biliary drainage (p = 0.001) was determined to be the only statistically significant variable associated with IAA by univariate analysis. Preoperative biliary drainage (p = 0.010) was determined to be the only statistically significant variable associated with postoperative death by univariate analysis.

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Table 11. PREOPERATIVE AND INTRAOPERATIVE VARIABLES ASSOCIATED WITH COMPLICATIONS AND DEATH IN PATIENTS WITH PANCREATIC/ PERIPANCREATIC ADENOCARCINOMA

Postoperative Hospital Stay

Median postoperative hospital stay was 11 days (range 4 to 132) for all patients undergoing pancreaticoduodenectomy. Median postoperative hospital stay was 12 days (range 4 to 52) for patients undergoing preoperative biliary drainage versus 11 days (range 6 to 132) for patients not undergoing preoperative biliary drainage (p = 0.886). Median postoperative hospital stay was 22 days (range 4 to 132) for patients with an IAA versus 11 days (range 4 to 42) for patients without an IAA (p < 0.001).

DISCUSSION

Pancreaticoduodenectomy continues to be accompanied by considerable morbidity rates 1–12 despite advances in surgical techniques, intraoperative management, postoperative care, and a trend toward a decreasing rate of postoperative mortality. Percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, and therapeutic biliary drainage by percutaneous and endoscopic techniques are universally available and widely used at most medical centers for the relief of obstructive jaundice in patients with pancreatic and peripancreatic pathology. In particular, therapeutic biliary drainage has become the standard of care in the management of obstructive jaundice in patients with unresectable pancreatic and peripancreatic disease. However, the efficacy of these biliary drainage techniques before surgery in patients with potentially resectable pancreatic and peripancreatic lesions has not been well established. Biliary instrumentation and biliary drainage have been well documented in the literature to be associated with infectious complications. 13–43 In this regard, relatively little information is currently available in the literature that specifically examines the effects of preoperative instrumentation and preoperative drainage of the biliary tract on postoperative morbidity and mortality rates after pancreaticoduodenectomy.

In our current study, rates of postoperative morbidity, infectious complications, IAA, and death are consistent with other large series in the literature. 1–12 We have clearly shown that preoperative biliary drainage is associated with an increased incidence of postoperative complications, infectious complications, IAA, and death. These associations were independent of the specific type of biliary drainage procedure performed and the number of biliary drainage procedures performed. Interestingly, preoperative biliary instrumentation alone had no association with postoperative complications, infectious complications, IAA, and death. These findings strongly suggest that the act of establishing an artificial conduit between the biliary tract and the gastrointestinal tract or the exterior, rather than the act of instrumenting the biliary tract alone, increases the risk of postoperative complications and death after pancreaticoduodenectomy.

To date, there have been multiple studies in the literature that have looked at biliary drainage in heterogeneous groups of patients with unresectable as well as resectable malignant biliary obstruction. However, few of these studies have specifically addressed the issue of preoperative biliary drainage exclusively in patients with potentially resectable pancreatic and peripancreatic lesions (Table 12 ). 2,7,10,44–54 Those studies conducted to address preoperative biliary drainage have either been retrospective 2,7,10,44–49 or prospective, randomized trials. 50–54

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Table 12. STUDIES EVALUATING THE EFFECT OF PREOPERATIVE BILIARY DRAINAGE ON POSTOPERATIVE MORBIDITY AND MORTALITY RATES

Retrospective trials from other institutions, 2,7,10,45–49 with one exception, 45 have failed to demonstrate any effect of preoperative biliary drainage (see Table 12). Denning et al 45 retrospectively looked at a group of 57 patients with obstructive jaundice, of which 25 underwent external biliary drainage before definitive pancreatic surgery. The patients undergoing preoperative biliary drainage had a significantly lower rate of postoperative morbidity; however, there was no significant difference in the rate of postoperative mortality, and only 6 patients underwent pancreaticoduodenectomy while 29 patients underwent palliative biliary–enteric bypass. Snellen et al 46 retrospectively looked at 67 patients with and without jaundice undergoing pancreaticoduodenectomy for pancreatic or peripancreatic carcinoma. They found no effect of preoperative biliary drainage on postoperative morbidity or mortality rates. Trede and Schwall 47 retrospectively looked at 285 consecutive patients with or without jaundice who underwent pancreaticoduodenectomy for both malignant and benign pancreatic disease. They stated that irrespective of the severity of jaundice, patients undergoing preoperative biliary drainage had lower postoperative morbidity and mortality rates. However, statistical analysis of their results for 150 jaundiced patients failed to show any overall statistical significance. Ceuterick et al 2 retrospectively looked at 79 consecutive patients with and without jaundice undergoing pancreaticoduodenectomy for pancreatic or peripancreatic carcinoma. They found no effect of preoperative biliary drainage on postoperative morbidity or mortality rates. Bakkevold and Kambestad 48 looked at 365 consecutive patients with a diagnosis of pancreatic or peripancreatic carcinoma, with or without jaundice, who were retrospectively analyzed for the effect of preoperative biliary drainage. In this study, 108 patients subsequently underwent pancreatic resection and 194 patients subsequently underwent biliary–enteric bypass. They found no significant difference in postoperative morbidity or mortality rates. Andersen et al 7 retrospectively looked at 117 consecutive patients with and without jaundice undergoing pancreaticoduodenectomy for pancreatic or peripancreatic carcinoma. They found no effect of preoperative biliary drainage on postoperative morbidity or mortality rates. Chou et al 10 retrospectively looked at 93 consecutive patients with and without jaundice undergoing pancreaticoduodenectomy for pancreatic or peripancreatic carcinoma. They found no effect of preoperative biliary drainage on postoperative morbidity or mortality rates. Karsten et al 49 looked at 241 consecutive patients undergoing preoperative endoscopic retrograde cholangiopancreatography for pancreatic or peripancreatic carcinoma with or without jaundice who were retrospectively analyzed for the effect of preoperative biliary drainage. In this study, 196 patients subsequently underwent pancreatic resection and 45 patients subsequently underwent biliary–enteric bypass. They found no significant difference in the rates of postoperative complications, infectious complications, or death.

Prospective, randomized trials, 50–54 with three exceptions, 51–53 have also failed to show any effect of preoperative biliary drainage (see Table 12). Hatfield et al 50 prospectively looked at a group of 57 patients with obstructive jaundice; 29 were randomly assigned to external biliary drainage before definitive surgery. There was no significant difference in postoperative morbidity or mortality rates; however, only 5 patients underwent pancreaticoduodenectomy while 34 patients underwent palliative biliary–enteric bypass. McPherson et al 51 looked at a group of 65 patients with obstructive jaundice; 34 were randomly assigned to external biliary drainage before definitive surgery. There was no significant difference in postoperative morbidity or mortality rates; however, the total hospital stay was significantly longer in patients undergoing preoperative biliary drainage. In this trial, only 7 patients underwent pancreaticoduodenectomy while 40 patients underwent palliative biliary–enteric bypass. Pitt et al 52 looked at a group of 79 patients with obstructive jaundice; 40 were randomly assigned to external biliary drainage before definitive surgery. There was no significant difference in postoperative morbidity or mortality rates; however, the total hospital stay was significantly longer in patients undergoing preoperative biliary drainage. In this trial, only 7 patients underwent pancreaticoduodenectomy while 63 patients underwent palliative biliary–enteric bypass. Lygidakis et al 53 looked at 38 consecutive patients undergoing preoperative endoscopic retrograde cholangiopancreatography for obstructive jaundice secondary to pancreatic or peripancreatic carcinoma who were randomly assigned to either preoperative biliary drainage or no preoperative biliary drainage, followed by pancreaticoduodenectomy. Patients undergoing preoperative biliary drainage had significantly fewer postoperative complications; however, there were no significant differences in IAA, wound infections, or postoperative death. Finally, Lai et al 54 looked at a group of 87 patients with obstructive jaundice; 37 were randomly assigned to undergo preoperative biliary drainage before definitive surgery. There was no significant difference in postoperative morbidity or mortality rates; however, only 23 patients underwent pancreaticoduodenectomy while 49 underwent palliative biliary–enteric bypass.

Because several of these studies, 2,7,10,44–49 including our own, were retrospective in nature, and because those that were prospective, randomized trials 50–54 were relatively small and involved few patients undergoing pancreaticoduodenectomy, we believe that the only way to answer this question adequately would be to conduct a large prospective, randomized trial comparing preoperative biliary drainage with no preoperative biliary drainage in patients with potentially resectable pancreatic and peripancreatic lesions amendable to pancreaticoduodenectomy. However, such a study is unlikely to be feasible because most patients presenting to tertiary referral centers, such as our own, have already undergone preoperative biliary instrumentation and drainage.

Based on the findings of our current study, we have adopted the following institutional guidelines for the preoperative evaluation of patients with pancreatic or peripancreatic pathology. First, in patients with pancreatic or peripancreatic lesions not associated with obstructive jaundice, preoperative biliary instrumentation and, in particular, preoperative biliary drainage are not warranted. Second, in patients with obstructive jaundice and potentially resectable pancreatic or peripancreatic lesions on CT scan, preoperative biliary instrumentation alone may be warranted to aid in the diagnosis and to delineate the extent of biliary involvement; however, preoperative biliary drainage is not indicated unless the patient has evidence of acute cholangitis or intractable symptomatic jaundice, or if neoadjuvant therapy is planned. In the case of obstructive jaundice and potentially resectable pancreatic or peripancreatic lesions on CT scan, one should consider early surgical consultation so that final determination of resectability can be made, including the use of laparoscopy. If resectability is confirmed, pancreaticoduodenectomy can be undertaken without the need for preoperative biliary drainage. Finally, in patients deemed to have unresectable disease by either CT scan or laparoscopy, nonsurgical biliary instrumentation and drainage are appropriate therapeutic interventions for relieving obstructive jaundice. We believe that avoiding preoperative biliary drainage whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions will improve patient outcome after pancreaticoduodenectomy by decreasing postoperative morbidity and mortality rates.

Acknowledgment

The authors thank Gerald R. Hobbs, PhD, of the Department of Statistics and the Department of Community Medicine of West Virginia University, for his assistance.

Footnotes

Correspondence: Stephen P. Povoski, MD, Dept. of Surgery, Robert C. Byrd Health Science Center, West Virginia University, Morgantown, WV 26506-9238.

Presented at the 51st Annual Meeting of the Society of Surgical Oncology, San Diego, California, March 28, 1998.

Accepted for publication April 16, 1999.

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