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Ann Surg. Aug 1999; 230(2): 143.
PMCID: PMC1420855

Preoperative Biliary Drainage and Surgical Outcome

Correspondence: Keith D. Lillemoe, MD, The Johns Hopkins Hospital, Dept. of Surgery, 600 N. Wolfe St., 679 Blalock, Baltimore, MD 21287.

“To stent or not to stent, that is the question.” Although the debate about the use of preoperative biliary drainage in patients with obstructive jaundice does not date back to the days of Shakespeare, the questions raised in the paper by Povoski and colleagues in this issue of Annals of Surgery are not new. 1 This article, however, addresses a very specific question related to the use of biliary stenting: the effect of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy.

This study is as good as it gets with respect to retrospective analysis of this question. It is a large single-institution study from a center with an excellent track record with this operation. The authors have clearly defined their complications and performed both univariate and multivariate analysis of multiple factors influencing the outcome after pancreaticoduodenectomy.

Their results are clear. Preoperative biliary drainage, be it endoscopic, percutaneous, or operative, is associated with an increased incidence of postoperative morbidity, infectious complications, intraabdominal abscess, and postoperative mortality. Of the large number of factors analyzed in this sophisticated statistical analysis, only preoperative biliary drainage influenced these outcomes. It would seem obvious based on these results that the current common practice of biliary stent placement, usually performed endoscopically, in patients with periampullary cancer, should be eliminated. In light of these results, why should a question remain? And why do I think that this paper is unlikely to change the current practice?

To put this paper into perspective, one must reexamine the numerous retrospective and prospective randomized studies that precede it. The authors have nicely summarized the results of these studies in their discussion and in Table 12, and conclude from their review that most prior retrospective studies have shown little advantage or disadvantage to preoperative biliary drainage in patients undergoing pancreatic surgery. I would add to their list that our group at Hopkins has recently found an increased incidence of both wound infection and pancreatic fistula in a retrospective comparison of stented patients versus nonstented patients undergoing pancreaticoduodenectomy. In the Hopkins series, however, with more than 500 patients analyzed, there was no effect on overall morbidity or mortality. 2 Furthermore, the Hepatobiliary Surgery group at Memorial Sloan-Kettering has recently published similar findings with respect to preoperative biliary stents in patients with proximal cholangiocarcinoma. 3

The prospective randomized studies, of course, deserve closer attention. Three of these studies used primarily external biliary drainage and included relatively few patients undergoing pancreaticoduodenectomy. All three of these studies were “negative” with respect to showing any difference between the patients undergoing drainage versus those undrained. However, based on the small number of patients randomized, these studies are unlikely to have had the “power” to support the null hypothesis. The strongest evidence in support of preoperative biliary drainage comes from a study by Lygidakis and colleagues 4 in which internal drainage decreased perioperative morbidity, but not mortality, in jaundiced patients undergoing pancreaticoduodenectomy. This small series is also most relevant in that it employed endoscopic drainage, which is the current standard practice for most jaundiced patients with periampullary cancer.

So based on the data—which at best provides mixed results—why do most patients still undergo preoperative biliary drainage? First, most patients with periampullary cancer at the time of diagnosis have symptomatic jaundice with icterus, pruritus, and some degree of abdominal pain. To some extent, it is hoped that stenting will provide symptomatic improvement. Second, cholangiography is still performed almost routinely in patients with obstructive jaundice. The diagnostic endoscopic retrograde cholangiogram is then followed in most cases by the placement of a stent. Both of these procedures represent the “barber phenomenon”—as in, when you go to the barber, you get a haircut. I believe that this trend will continue as long as endoscopists become involved in the early evaluation of patients with periampullary cancer. Although to most experienced surgeons, a dilated biliary tree and a pancreatic mass represents a straightforward diagnosis, most of these patients will still end up “in the barber’s chair” (endoscopic suite). It might be hoped that the more widespread availability of magnetic resonance cholangiopancreatography might decrease the need for invasive cholangiography and subsequent stent placement.

The third and final argument in favor of preoperative biliary drainage in patients with periampullary cancer is the potential for delay in definitive surgical management. It is hard to argue with this indication. Surgical management of periampullary cancer has become increasingly centered at high-volume institutions for the past decade. This trend is supported by a number of reports in the literature, including one from Memorial Sloan–Kettering, that have demonstrated decreased perioperative mortality, length of hospital stay, and hospital costs at high-volume centers when compared to centers performing a lower volume of pancreaticoduodenectomies. 5–7 This change in referral pattern adds time to the overall treatment process for patient travel, coordination of consultation appointments, the inevitable delay in third-party payor referral, and finally scheduling an OR date at the tertiary center. Furthermore, in an attempt to improve surgical outcomes, many major centers are performing preoperative staging laparoscopy or neoadjuvant therapy that will further delay definitive surgical therapy. The bottom line is that the symptomatic jaundiced patient may not be able to go without biliary drainage for this period of time, either due to symptoms or to the effect of complete biliary obstruction on liver function. In these specific patients, therefore, preoperative biliary drainage may be necessary.

In conclusion, I agree with Dr. Povoski and his colleagues that a large prospective randomized study is needed to settle this question once and for all. I also agree that it is unlikely that such a study will ever be done because in most cases the decision to place a biliary stent occurs before the surgeon becomes involved in the decision-making process. Until that time, it is hoped that the clear-cut results of this paper become widely disseminated, particularly to physicians managing these patients at the initial stages of diagnosis. Unfortunately, this group generally includes internists and gastroenterologists who are not the regular readership of Annals of Surgery. It is our mission, therefore, to carry this message to these colleagues and hopefully better direct the care of such patients.


1. Povoski SP, Karpeh MS, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999; 230: 131–142. [PMC free article] [PubMed]
2. Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase post-pancreaticoduodenectomy complications? J Gastrointestinal Surg (in press). [PubMed]
3. Lygidakis NJ, van der Heyde MN, Lubbers MJ, et al. Evaluation of preoperative biliary drainage in the surgical management of pancreatic head carcinoma. Acta Chir Scand 1987; 153: 665–668. [PubMed]
4. Hochwald SN, Burke EC, Jarnagin WR, et al. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 1999; 134: 261–266. [PubMed]
5. Gordon TA, Burleyson GP, Tielsch JM, Cameron JL. The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg 1995; 221: 43–49. [PMC free article] [PubMed]
6. Lieberman MD, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995; 222: 638–645. [PMC free article] [PubMed]
7. Birkmeyer JD, Finlayson SRG, Tosteson ANA, et al. Effect of hospital volume on in-hospital mortality with Whipple procedures. Surgery 1998; 125: 250–256. [PubMed]

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