All surgeons treat patients with pancreatic head cancer. One of the first signs of this malignant disease is jaundice. To perform or not to perform a preoperative biliary drainage (PBD) is still a matter of debate. However some recent data supports the option not to preoperatively drain the biliary tree if surgery is imminent.
In 1935 Whipple developed a 2-stage pancreatoduodenectomy, with a gastroenterostomy and a cholecystogastrostomy performed 3-4 weeks prior to resection surgery. The first stage would attenuate liver disfunction and coagulopathy. These aims justify the PBD strategy advocated by some authors. Nowadays PBD is usually achieved via placement of an endobiliary stent by endoscopic retrograde cholangiopancreatography (ERCP). But... This strategy is being contradicted by recent studies.
In 2017 Scheufele et al. from the Department of Surgery of the Technical University of Munich, Germany, published in "Surgery" the biggest meta-analysis in the last two decades about this issue. The objective: to evaluate the impact of PBD of obstructive jaundice due to pancreatic head cancer on postoperative outcome. A total of 6214 patients were included, 3287 submitted to PBD and 2927 submitted to surgery first. Results are clear!
In sum, the authors report an increase in the overall complications rate in the PBD arm (p=0,002), which is more pronounced in the randomised trials included in the meta-analysis (p<0,00001). Also the surgical site infection (SSI) rate is increased in the PBD group versus the "surgery first" group (13,7 % vs 7,8 %, p<0,00001). Pancreatic fistula, intra-abdominal abscess, and mortality rate, were similar in both groups.
These results are supported by Fang et al. from the Cochrane database. Fang and fellows conclude that "biliary drainage should not be applied routinely in patients with obstruction jaundice prior to imminent operative intervention". The results presented by Scheufele et al. are also supported by the latest randomised controlled trial conducted by Van der Gaar et al., showing an increased complication rate in patients submitted to PBD before surgery.
Although these recent studies clearly advocate the non systematic use of PBD due to its negative effect on postoperative outcome, >50% of patients referred to specialised centres still undergo PBD and >75% are submitted to it before consulting a surgeon. So... When should preoperative biliary stenting be offered? Scheufele et al. present three clear indications:
cholangitis
severe symptomatic jaundice (pruritus)
neoadjuvant chemotherapy (surgery delay)
Additionally patients without fever, bacteriemia and disturbance of coagulation should not receive PBD routinely. According to the authors, since jaundice alone and alteration of liver parameters are not linked to worst results, these patients do not benefit from PBD.
It looks clear that the indications for preoperative biliary drainage are very limited in patients with obstructive jaundice due to pancreatic head cancer who are candidates for imminent resection surgery. Surgeons and gastroenterologists must work together to avoid an harmful procedure before a potential curative surgery.
A final reference to an idea that Scheufele et al. present in their interesting paper. Centralization! Several authors state that centralization increase R0 resection in pancreatic cancer. Additionally survival rate after pancreatic resection is significantly improved in hight-volume centres. However there is a problem. Centralization will lead to certain delay of surgery, which will make PBD inevitable in a patient who will be waiting longer than he should for operative treatment.
So... Will postoperative overall complications rate be increased because of centralization? Think about it while avoiding preoperative biliary drainage...
Link to PubMed:
Scheufele F, Schorn F, Demir IE, et al. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in pancreatic head: a meta-analysis of current literature. Surgery 2017; 161(4): 939-950.
Dr. Carlos Eduardo Costa Almeida
General Surgeon