The effect of preoperative biliary drainage on postoperative complications of pancreaticoduodenectomy: a triple center retrospective study

Abstract

Background Biliary obstruction which is a major complication of pancreas and periampullary tumors could result in cholangitis, coagulopathies, gastrointestinal symptoms, and impaired wound healing. Pancreaticoduodenectomy (PD) is still the standard approach for pancreas resection and imposes high risk of morbidity and mortality to patients. To reduce the high risk of PD and address the biliary obstruction, the use of preoperative biliary stenting was increased. However, available literature doubts its efficiency. Methods A total of 147 patients who underwent PD between September 2012, and February 2022, at three medical centers were identified. Patients were grouped based on biliary stent placement. Non-jaundiced patients with and without preoperative biliary drainage (PBD) were compared. Results The incidence of overall complications (34.2% versus 45.8%) and mortality (17.8% versus 24.3%) did not differ in the PBD group compared to the no PBD group. There was no difference in complications and mortality in non-jaundiced patients with and without PBD. Patients with drainage duration of > 30 days experienced more overall complications compared to patients with less than 30 days drainage duration (12 (50.0%) and three (15.8%) patients, respectively, p-value = 0.019). Conclusions PBD does not significantly increase the post-operative burden on patients who undergo PD. However, we cannot overlook the financial burden that PBD places on the patient and the healthcare system, as well as the difficulties related to endoscopic retrograde cholangiopancreatography (ERCP). Therefore, biliary stenting should not be routinely practiced in the absence of a valid indication, such as severe jaundice, pruritus, cholangitis, delayed surgery for neoadjuvant treatment, or referral to a tertiary facility.

Impact of preoperative biliary drainage on pancreaticoduodenectomy complications in periampullary tumors: A case-control study

“…In the literature, mortality rates vary between 2% and 5%, and no signi cant effect of biliary drainage on mortality has been shown [4,7,10,21]. In this study, surgery-related mortality was 6.4%, and PBD did not affect mortality.…”

“…This is particularly apparent in patients who underwent EBD, and it has been emphasized that the decision and type of PBD are independent risk factors for complications, and early stent-free surgery has been recommended [9,23]. However, some studies recommend the routine use of PBD in patients with severe hyperbilirubinemia (bilirubin level > 15 mg/dl) [4,10]. Therefore, research and discussions regarding the effect of PBD on the morbidity and mortality of malignant patients with obstructive jaundice are ongoing.…”

“…However, PBD has been shown to increase major postoperative complications (POPF, DGE, biliary leakage, abdominal collection, and SSI), cause stentrelated complications, and prolong LOS [20,21]. However, some studies could not demonstrate its effect on major morbidity and mortality [8,10]. Meanwhile, some studies showed that PBD increases the incidence of SSI without increasing mortality and major complications [5,7,8].…”

“…Nevertheless, there is no clear consensus regarding the level of bilirubin. Some studies recommend biliary drainage in patients with bilirubin levels > 10 mg/dl [10]. The Verona group reported that EBD did not affect postoperative major complications or mortality but increased the incidence of surgical site infection (SSI), and it was emphasized that the tendency toward this complication increased in patients with a bilirubin value above 7.5 mg/dl and that PBD should be performed [8].…”

Surgical Site Infections in Patients of Periampullary Carcinoma Undergoing Delayed Bile Duct Division (COMBILAST) in Whipple’s Procedure: A Prospective Cohort Study

“…As per few studies, PBD has no effect on the incidence of significant post-operative complications after pancreaticoduodenectomy [ 23 , 24 ]. However, contradicting results have been reported by other authors [ 25 ].…”