Preoperative biliary drainage in pancreatic head adenocarcinoma

case report and literature review

Abstract

Preoperative biliary drainage (PBD) is a method used to reduce the consequences of cholestasis in patients with obstructive jaundice due to peri-ampular tumors (pancreatic head common duct, papila of Vater or duodenum). However, its indication is controversial. We report a case where there was no consensus between the assistant doctor and the surgery team regarding the treatment, followed by a literature review aiming to best define the indications for PBD versus early surgery in resectable tumors of the pancreatic head. The research went back to 1935, when Whipple first described the theoretical benefits of PBD when compared to direct surgery. Many non-randomized, randomized and multicentric studies, meta-analysis and reviews were evaluated on the main research platforms in the present paper. Results are variable and do not allow an unequivocal definition. Papers with the highest level of evidence are the systematic reviews by Cochrane which suggest the lack of evidence in favour or against routine PBD. Most studies suggest that drainage is related to greater complication rate after surgery. Percutaneous transhepatic biliary drainage (PTBD) was compared to endoscopic retrograde cholangiopancreatography (ERCP) and no differences regarding costs, hospitalization length or outcomes were found. We conclude that preoperative biliary drainage should be avoided whenever definitive resection is available within 7 days in a reference centre. The practice may be benefic in cases of cholangitis, preoperative instability or unavailability of early referal to a specialized center.