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

Abstract

Rationale Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results. Findings For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits. Conclusion The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.

Preoperative biliary drainage versus direct surgery for perihilar cholangiocarcinoma: A retrospective study at a single center

“…This could explain the lower rate of vascular resection and reconstruction in the current study. Among patients with obstructive jaundice, PBD is the best way to reduce the bilirubin level to reverse cholestasis-associated liver dysfunction and impaired hepatic regeneration (23). However, there are no guidelines or indications regarding the level of bilirubin that warrants a patient undergoing PBD.A ROC curve was used in the current study to find the cut-off value for TB to indicate PBD.…”

Preoperative factors predicting poor outcomes following laparoscopic choledochotomy: a multivariate analysis study

“…The presence of toxic substances, such as BIL and bile salts, impaired liver function, and altered nutritional status due to obstructive jaundice have been characterized as factors for the development of complications, including acute renal failure, cardiovascular depression, hemorrhage from vitamin K deficiency and septicaemia. 14,15 An obstructed biliary tree is likely to be infected and, as a consequence, there will be a higher incidence of severe chronic cholecystitis found at operation, necessitating conversion. 8 In addition, patients with higher BIL were more likely to undergo an emergency operation, and an emergency operation was a risk factor for poor outcomes.…”

Effect of Post-ERCP Pancreatitis on Perioperative Factors of Pancreaticoduodenectomy

“…Presently, the necessity for preoperative biliary drainage is controversial. In several studies, preoperative biliary drainage reduced morbidity and mortality after surgery for periampullary cancer [23] [24]. However, recent studies showed that the overall complication rate in patients undergoing preoperative biliary drainage was higher than that in patients who proceeded directly to surgery and that the procedure increased the rate of complications [25] [26].…”