A Meta-analysis on the Efficacy of Preoperative Biliary Drainage for Tumors Causing Obstructive Jaundice

Abstract

ObjectiveTo review the effectiveness of preoperative biliary drainage (PBD) in patients with obstructive jaundice resulting from tumors. Summary Background DataThis was a systematic review, including a meta-analysis, of randomized controlled trials and comparative cohort studies conducted worldwide and published between 1966 and September 2001, classified on methodologic strength and subdivided into level 1 (randomized controlled trials) and level 2 (comparative cohort studies). MethodsComparison was made of PBD versus no PBD in jaundiced patients undergoing resection of a tumor. Outcome measures were in-hospital death rate, overall complications resulting from the treatment modality (drainage-and surgery-related complications), and hospital stay. Effect sizes were calculated and combined in meta-analyses. Relative differences (%) were calculated to compare effects on outcome measures. ResultsFive randomized controlled studies comprising 302 patients met the inclusion criteria for level 1 studies, and 18 cohort studies comprising 2,853 patients met the criteria for level 2 studies. Meta-analysis of level 1 studies showed no difference in the overall death rate between patients who had PBD and those who had surgery without PBD. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. At level 2, there was no difference in the death rate between the two treatment modalities. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. If PBD had been without complications, then complications would be in favor of drainage based on level 1 studies, and no difference based on level 2 studies. Further, PBD was not able to reduce the length of postoperative hospital stay compared with surgery without PBD; instead, it prolonged the stay. ConclusionsThis meta-analysis shows that PBD with current standards for patients with obstructive jaundice resulting from tumors carries no benefit and should not be performed routinely. The potential benefit of PBD in terms of postoperative rates of death and complications does not outweigh the disadvantage of the drainage procedure. Only if PBD-related complications could be reduced by 27% and consequently diminish hospital stay could PBD be beneficial. Further randomized controlled trials with improved PBD techniques are necessary.

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

“…49 A systematic review from our institution summarized all retrospective and prospective studies, published between 1966 and 2001, with the aim to evaluate the efficacy of drainage in jaundiced patients, compared to patients that underwent direct surgical treatment. 50 Outcome measures of the meta-analysis were in-hospital death rate, overall complications resulting from the treatment modality (PBD-and surgery-related complications), and hospital stay. Five randomized controlled studies comprising 302 patients (level I evidence) and 18 cohort studies comprising 2,853 patients (level II evidence) met inclusion criteria and were analyzed.…”

LOW MORTALITY RATE IN 97 CONSECUTIVE PANCREATICODUODENECTOMIES: the experience of a group

“…Some series show no mortality (2,10,13,34) . However, postoperative morbidity has not experienced the same decline, being around 30%-60% in recent reports (14,31,35,37,41) .…”

Diagnóstico, estadiamento e tratamento cirúrgico do adenocarcinoma de pâncreas

“…Em metanálise publicada por Sewnath et al 38, onde foram incluídos 23 estudos, e 3155 pacientes, os resultados sugerem que a drenagem pré-operatória não trás benefí-cios e por isso não deve ser realizada de rotina no pré-operatório de pacientes portadores de icterícia obstrutiva. Várias objeções metodológicas impossibilitam adequada conclusão desta metanálise: estudos não randomizados foram incluídos, o AP representou pouco menos da metade dos pacientes arrolados no estudo, o tipo de procedimento cirúrgico não foi uniformizado (pancreatectomias, hepatectomias foram incluídos), um grande número de pacientes foi submetido à drenagem biliar externa com seus riscos superiores à drenagem interna por endoscopia 38 .…”

“…Várias objeções metodológicas impossibilitam adequada conclusão desta metanálise: estudos não randomizados foram incluídos, o AP representou pouco menos da metade dos pacientes arrolados no estudo, o tipo de procedimento cirúrgico não foi uniformizado (pancreatectomias, hepatectomias foram incluídos), um grande número de pacientes foi submetido à drenagem biliar externa com seus riscos superiores à drenagem interna por endoscopia 38 .…”