Significance of Self‐Expandable Metallic Stent for Postoperative Intra‐Abdominal Infection After Pancreatoduodenectomy in Patients With a Hard Pancreas

Objective: Preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) has limited, but definite indications. Patients are often referred to high volume centers after PBD. This study seeks to compare the magnitude of complications between different PBD modalities (Plastic and SEMS) in patients undergoing PD at our oncology center. Material and Methods: The Electronic Medical Records of the patients who had undergone PD between August 2011 and May 2019 were retrospectively analyzed. Chi-square and Mann-Whitney U test were used to test for statistically significant difference between categorical and nonparametric continuous variables respectively. Results: Between August 2011 to May 2019, 167 patients with mean age of 57 years (117 males) underwent PD. PBD was performed in 64% patients with majority (83, 78%) done outside. The plastic stent (PS=74, 89%) was commonest in this group and three (4%) had self-expanding metal stents (SEMS). In our hospital, three fourth PBD was done with SEMS. There was no statistically significant difference of median pre-stenting serum bilirubin (p=0.5) between us and other centers. In pre-operative waiting period 25% patients experienced stent related complications,19 (24.6%) in the PS group and three (14.8%) in SEMS (p=0.29), commonest being cholangitis (n=23,85%). The median interval between PBD and complications was 29 days (range 0-101). Apart from post operative surgical site infection PS and SEMS group did not differ in peri and post operative outcomes. Conclusion: Plastic stent continues to be the popular modality of PBD in low-income countries. If surgery is not delayed after PBD in our experience PS seemed to perform equally effectively.

INTRODUCTION Biliary obstruction secondary to tumor infiltration of the bile duct is a very frequent complication of pancreatic cancer. Pancreatic cancer is actually responsible of jaundice in two out of three patients with malignant biliary obstruction in clinical trials.[1] In addition, obstructive jaundice is often the first clinical sign of the disease. Obstructive jaundice limits or even precludes the use of chemotherapy, both in a neoadjuvant and palliative settings. Biliary drainage becomes, therefore, one of the cornerstones in the management of patients with pancreatic cancer. Transpapillary stenting is the approach of choice for biliary drainage in patients with pancreatic cancer and obstructive jaundice. The indications of preoperative biliary stenting, as well as relevant aspects of biliary drainage in the context of unresectable pancreatic cancer (metal or plastic stents, covered or uncovered metal stents, and new alternatives for the present and the future), are discussed in the present overview. PREOPERATIVE BILIARY DRAINAGE FOR RESECTABLE PANCREATIC CANCER Preoperative biliary drainage increases complications compared with surgery without preoperative drainage.[2] Nevertheless, some patients may benefit from preoperative relief of jaundice; these include patients with untreatable pruritus, acute cholangitis, or renal dysfunction as a consequence of obstructive jaundice. In addition, patients in whom the surgical procedure is delayed due to neoadjuvant therapy, need of nutritional support in cases of high risk of malnourishment, or due to logistic issues, also require a preoperative biliary stenting. The endoscopic transpapillary approach is generally preferred for biliary drainage in this preoperative setting, but complications should not be underestimated.[2] In fact, complications such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, cholangitis, or hemorrhage may preclude patients from further curative surgical resection of the tumor. In this context, the use of maneuvers aiming at reducing the risk of post-ERCP complications (e.g., rectal indomethacin or diclofenac, pancreatic duct stenting, adequate hydration, early precut in difficult cannulation or antibiotics) should be maximized. For preoperative biliary drainage, the use of self-expandable metal stents (SEMS) should be preferred over plastic stents since they are associated with significantly lower complication rate and stent dysfunction, with a similar surgical complication rate.[34] BILIARY DRAINAGE FOR UNRESECTABLE PANCREATIC CANCER Palliative surgical or endoscopic transpapillary drainage? Endoscopic and surgical biliary drainage in patients with unresectable pancreatic cancer show similar technical success rate and long-term efficacy.[5] Endoscopic biliary drainage is associated with less complications (risk ratio [RR] 0.60; 95% confidence interval [CI] 0.45–0.81), shorter hospital stay, better quality of life, and lower cost than the surgical palliative approach.[5] Based on these results, a minimally invasive transpapillary approach is preferred for biliary drainage in patients with unresectable pancreatic cancer. Transpapillary biliary stenting for unresectable pancreatic cancer Although new devices and recent development of therapeutic endoscopic ultrasound have opened new minimally invasive options for biliary drainage, endoscopic transpapillary biliary stenting continues to be the therapy of choice for obstructive jaundice in the majority of patients with unresectable pancreatic cancer. Endoscopic transpapillary stenting is feasible in >90% of the cases in experienced hands. In addition, short-term efficacy, defined as jaundice and pruritus relief, is higher than 80%.[6789] Different studies have shown however that jaundice and pruritus relief is lower in patients with very high hyperbilirubinemia (in whom symptom relief takes frequently longer), liver metastasis (due to a lesser role of common bile duct obstruction in the pathogenesis of hyperbilirubinemia) and atypical biliary obstruction.[6789] Self-expandable metal stents or plastic stents for unresectable pancreatic cancer? Both SEMS and plastic stents are commercially available for endoscopic biliary drainage. Choosing one over the other should be based on aspects such as dysfunction rate and need of reinterventions, complication rate, patient survival and cost. A large number of studies have reported on the dysfunction rate of SEMS and plastic stents in patients with malignant distal biliary obstruction. These studies have been included in a recent meta-analysis showing a lower dysfunction rate for SEMS (21.9%) compared to plastic stents (48.9%), with a relevant risk difference of 27%.[1] Time to stent dysfunction is also significantly longer for SEMS (250 ± 104 days) than for plastic stents (124 ± 104 days) (P < 0.001). This superiority of SEMS over plastic stents is associated with a lower need of reintervention rate (21.4% vs. 56.6%, risk difference 35%).[1] As with any other ERCP procedure, complications associated with endoscopic transpapillary biliary drainage in patients with unresectable pancreatic cancer include mainly pancreatitis, cholangitis, bleeding, perforation, cholecystitis, and liver abscess. The complication rate is of about 13% after both SEMS and plastic stents.[1] As mentioned above, the use of any maneuver aiming at reducing the risk of post-ERCP complications should be maximized specifically in patients with unresectable pancreatic cancer, in whom severe complications may prevent any further oncological therapy. The question of whether sphincterotomy before SEMS placement is useful to reduce the risk of post-ERCP pancreatitis is a matter of debate. The risk of pancreatitis (7%–9%), cholangitis, stent migration, and stent dysfunction appears to be similar in patients undergoing or not undergoing sphincterotomy before SEMS.[10] The risk of bleeding is significantly higher after sphincterotomy, and thus sphincterotomy before SEMS placement cannot be generally recommended.[10] New multicenter, randomized clinical trials are currently ongoing aiming at definitively answering this question. Pancreatic cancer is a disease with dismal prognosis. Survival of patients with unresectable pancreatic cancer is short. The choice of SEMS or plastic stents for biliary drainage in these patients has probably not a major impact, but a recently published meta-analysis has reported on a statistically significant longer survival after SEMS compared to plastic stent (median survival 187 d vs. 162 d, P < 0.001).[1] Finally, cost analysis in this setting is not an easy task. This is mainly due to different factors included in the cost analysis in different studies (full treatment or stent cost and number of stents exchanged). Taking this limitation into account, cost evaluation generally supports SEMS over plastic stents due to a lower full treatment cost. What is the optimal self-expandable metal stents (uncovered, partially covered or fully covered)? Similarly to what it has been described for SEMS and plastic stents, choosing among uncovered, partially covered, and fully covered stents depend on factors such as stent patency and dysfunction, as well as complications and patient survival. All these factors appear to be similar with all these SEMS, with the exception of the cause of stent dysfunction. Compared to uncovered stents, dysfunction of covered stents is more often due to sludge formation (RR 2.47; 95% CI 1.36–4.50), stent migration (RR 9.33; 95% CI 2.54–34.24), and tumor overgrowth (RR 1.76; 95% CI 1.03–3.02), but less often due to tumor ingrowth (RR 0.25; 95% CI 0.12–0.52).[11] ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY - GUIDED INTRADUCTAL ENDOSCOPIC ABLATION The development of new devices and probes to apply radiofrequency ablation (RFA) into the bile duct in patients with malignant biliary obstruction may change in the future the way obstructive jaundice is managed in patients with pancreatic cancer today. Preliminary studies have reported on the use of ERCP-guided intraductal RFA before SEMS insertion.[121314] These studies show that ERCP-guided RFA does not significantly influence stent patency, but it appears to be an independent predictor of longer survival in patients with unresectable pancreatic cancer. These promising results should encourage us to further evaluate the role of ERCP-guided RFA for malignant obstructive jaundice in large, properly designed, and multicenter clinical trials.

Background and study aimsAdequate preoperative biliary drainage (PBD) is recommended in most patients with resectable perihilar cholangiocarcinoma (pCCA). Most expert centers use endoscopic plastic stents rather than self-expanding metal stents (SEMS). In the palliative setting, however, use of SEMS has shown longer patency and superior survival. The aim of this retrospective study was to compare stent dysfunction of SEMS versus plastic stents for PBD in resectable pCCA patients. Patients and methodsIn this retrospective, multicenter, international cohort study, patients with a potentially resectable pCCA who underwent initial endoscopic PBD were included from 2010-2020. Stent failure was a composite endpoint of cholangitis and/or re-intervention due to adverse events or insufficient PBD. Other adverse events, surgical outcomes, and survival were recorded. Propensity score matching (PSM) was performed on several baseline characteristics. Results474 patients had successful stent placement, of whom 61 received SEMS and 413 plastic stents. PSM (1:1) resulted in two groups of 59 patients. Stent failure occurred significantly less in the SEMS group (31% vs 64%, p<0.001). Besides less cholangitis after SEMS placement (15% vs 31%, p = 0.012), other PBD-related adverse events did not differ. The number of patients undergoing surgical resection was not significantly different (46% vs 49%, p = 0.71). Complete intraoperative SEMS removal was successful and without adverse events in all patients. ConclusionsStent failure was lower in patients with SEMS as PBD compared to plastic stents in patients with resectable pCCA. Removal during surgery was well feasible. Surgical outcomes were comparable.

IntroductionDecompression by ERCP and stenting is often the first-line management in cases of malignant biliary obstruction. Not infrequently this is performed to relieve symptoms prior to tissue diagnosis and definitive...

Improving outcomes in management of pancreatic cancer remains a challenge, owing to advancement of the disease at presentation. Only 15-20% patients are diagnosed at a resectable or borderline resectable stage (1). During the past 1-2 decades, adjuvant chemotherapy with surgery first approach did not bring a significant survival benefit (2-4). Recent studies have shown that neoadjuvant chemoradiation therapy results in better post surgical outcomes for potentially resectable pancreatic cancer (5-7). This has led to change in management strategy in many pancreatic cancer centers from initial surgery to now neoadjuvant therapy followed by surgery, especially in borderline resectable pancreatic cancer. In this approach, preoperative therapy lasts approximately 3 months and is followed by a 1-month recovery period before surgery. Therefore, patients who have biliary obstruction due to cancer in the head of the pancreas need drainage while receiving the treatment and waiting to undergo surgery. Effective biliary drainage is essential to prevent liver toxicity due to chemotherapeutic agents. Furthermore, during the period of neoadjuvant chemoradiation, patients may become immuno-compromised, and the patients may not tolerate recurrent biliary obstruction with cholangitis, or any complications from repeated endoscopic procedures. Therefore, it is crucial to avoid unnecessary interventions including endoscopic procedures during this period. Among various kinds of biliary stents, self-expanding metal stents (SEMS) have been increasingly used in treating malignant distal biliary obstruction because of their long duration of patency. By design, SEMS have a large diameter and minimal surface area on which bacterial biofilm can form, thus reducing the risk of obstruction. In the study by Adams et al. published in this issue of Journal of Gastrointestinal Oncology, the authors have compared outcomes of placing self-expanding metal stents (SEMS) vs. plastic stents for pancreatic cancer patients undergoing neoadjuvant therapy. In this retrospective study, 52 patients with pancreatic cancer underwent ERCP and had placement of either SEMS or plastic stents before or during the treatment. Keeping in line with prior studies, the complications were 7 times higher among patients with plastic stents than with metal stents. Not only the complications were more common, their occurrence was also significantly earlier in the plastic stent group. In addition, the study showed a higher rate of hospitalization in patients with plastic stent group. Finally, the authors concluded that SEMS, not plastic stents, should be used in this setting, due to a lower rate of complications, hospitalizations, and longer stent patency. Similarly, multiple retrospective and prospective studies have proven superiority of SEMS to plastic stents in drainage of malignant bile duct obstruction. Three studies published by our group found that, compared with plastic stents, SEMS placement reduced the number of ERCPs and the episodes of cholangitis in patients who underwent preoperative chemoradiation (8-10). We found no increase in pancreaticoduodenectomy related morbidity or mortality among patients who underwent SEMS placement for pre-operative drainage. Likewise, other centers have published their experience comparing the outcomes of biliary SEMS to plastic stents. In a retrospective study of 29 patients with pancreatic cancer undergoing pre-operative biliary drainage, authors found no stent dysfunction or complications during the pre-operative period in patients who underwent SEMS placement compared to 39% patients requiring re-interventions in the plastic stent group (11). Congruently, in a prospective study evaluating the outcomes of SEMS in 55 patients receiving neoadjuvant therapy for pancreatic cancer, stent malfunction occurred only in 15% of patients by 260 days (12). There were 27 patients in the study who later underwent pancreaticoduodenectomy, and the presence of stent did not interfere with surgery in any patient. SEMS has also been proven to be more cost-effective. In summary, with recent advances in neoadjuvant chemoradiation therapy, there seems to be a significant improvement in overall survival among potentially resectable patients who undergo pancreaticoduodenectomy after the treatment. Consequently, the approach for neoadjuvant chemoradiation therapy prior to pancreaticoduodenectomy is gaining wider acceptance and more patients with pancreatic cancer will require pre-operative biliary drainage in the future. Current data unequivocally supports the use of SEMS for patients presenting with malignant biliary obstruction due to potentially resectable pancreatic cancer undergoing neoadjuvant chemoradiation therapy. On the other hand, for patients who have resectable pancreatic cancer, many centers may consider to proceed with curative surgery upfront. In such cases where patients may be undergoing curative surgery without neoadjuvant therapy, SEMS or any other stents may not be warranted. Lastly, when the stage of disease and treatment plan are not completely defined at the time of diagnosis, the vast majority of patients with symptomatic malignant distal bile duct obstruction may be best served by placement of SEMS rather than a plastic stent at the initial endoscopic intervention, due to the superior patency, lower rate of complications, and cost-effectiveness of SEMS.

Biliary and pancreatic stents

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.

Neoadjuvant chemotherapy (NAC) improves the rate of curative resection and overall prognosis in patients with resectable or borderline resectable pancreatic cancer. The treatment period from the initiation of NAC to surgery typically ranges from 2 to 6 months. In cases of malignant biliary obstruction caused by pancreatic cancer, maintaining preoperative biliary drainage (PBD) until surgery is essential to continue NAC. Minimizing adverse events related to endoscopic biliary drainage and avoiding perioperative adverse events are crucial. Plastic stents (PSs) are commonly used for PBD; however, the extended duration of PBD required for NAC increases the risk of recurrent biliary obstruction (RBO), potentially leading to discontinuation of NAC. Therefore, preventing RBO during PBD in patients with pancreatic cancer receiving NAC is important. The placement of self-expandable metal stents (SEMSs) for PBD significantly reduces the rate of RBO compared with PS placement. Although SEMS placement may increase the risk of pancreatitis or cholecystitis, its effect on postoperative outcomes is comparable to that of PS placement. Given their lower rate of RBO, SEMSs are considered more suitable than PSs for PBD in patients with pancreatic cancer receiving NAC.

Objective To analyze the related risk factors for delayed gastric emptying (DGE) after pancreaticoduodenectomy. Methods Clinical data on 308 patients who underwent pancreaticoduodenectomy at Ningbo Lihuili hospital from January 2009 to December 2014 were retrospectively analyzed, and patients were divided into DGE group and non-DGE group. Univariate analysis and multivariate logistic regression analysis were used to study the risk factors associated with DGE during perioperative period. Results DGE occurred in 55 patients (17.9%). The incidences of grade A, grade B and grade C DGE were 7.1%(22/308), 6.2%(19/308) and 4.5%(14/308), respectively. The univariate analysis showed the method of pancreatic digestive tract reconstruction (pancreaticogastrostomy or pancreaticojejunostomy), postoperative pancreatic fistula, postoperative biliary fistula and postoperative intraabdominal infection were risk factors for DGE after surgery. Multivariate analysis indicated that the method of pancreatic digestive tract reconstruction (OR=1.19, P=0.046), postoperative pancreatic fistula (OR=1.33, P=0.014), postoperative biliary fistula (OR=1.43, P=0.047) and postoperative intraabdominal infection (OR=1.51, P=0.001) were independently associated with DGE. Postoperative pancreatic fistula (OR=3.692, P=0.021)and intraabdominal infection (OR=3.725, P=0.003)were also the independent risk factors for Grade B and Grade C DGE. Conclusions DGE after pancreaticoduodenectomy was strongly related to the postoperative complications. Postoperative pancreatic fistula, biliary fistula and intraabdominal infection were associated with increased risk of DGE, while pancreaticogastrostomy reduced the incidence of DGE by decreasing the incidence of pancreatic or biliary fistula. Key words: Pancreaticoduodenectomy; Delayed gastric emptying; Postoperative complications; Risk factors

To compare the complication rates and overall costs of self-expandable metal stents (SEMS) and plastic stents (PS) in clinically indicated preoperative biliary drainage (PBD) prior to a pancreatoduodenectomy (PD). We conducted an Australian multicentre retrospective cohort study using the databases of four tertiary hospitals. Adult patients who underwent clinically indicated endoscopic PBD prior to PD from 2010 to 2019 were included. Rates of complications attributable to PBD, surgical complications and pre-operative endoscopic re-intervention were calculated. Costing data were retrieved from our Financial department. Among the 157 included patients (mean age 66.6 ± 9.8 years, 45.2% male), 49 (31.2%) received SEMS and 108 received PS (68.8%). Baseline bilirubin was 187.5 ± 122.6μmol/L. Resection histopathology showed mainly adenocarcinoma (93.0%). Overall SEMS was associated less complications (12.2% vs. 28.7%, p=0.02) and a lower pre-operative endoscopic re-intervention rate (4.3 vs. 20.8%, p=0.03) compared with PS. There was no difference in post-PD complication rates. On multivariate logistic regression analysis, stent type was an independent risk factor of PBD complication (OR of SEMS compared to PS 0.24, 95% CI 0.07-0.79, p=0.02) but not for any secondary outcome measures. Upfront material costs were $56USD for PS and $1991USD for SEMS. Accounting for rates of complications, average costs were similar ($3110USD for PS and $3026USD for SEMS). In resectable pancreaticobiliary tumours, SEMS for PBD was associated with reduced risk of overall PBD-related complications and pre-surgical endoscopic reintervention rates and was comparable to PS in terms of overall cost.

Background and study aims Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities.Patients and methods In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications.Results The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %;P = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance.Conclusion This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions.

The role of preoperative biliary drainage (PBD) in the management of jaundiced patients with resectable pancreatic cancer (RPC) is controversial. Obstructive jaundice determines hepatic dysfunction which can increase the operative risks. Experimental studies demonstrated that PBD could be associated with improved surgical outcomes. However, clinical studies did not confirm these findings. Initial clinical studies conducted with percutaneous approach failed to demonstrate a real advantage for patients undergoing PBD before pancreaticoduodenectomy. Overall morbidity was higher in patients undergoing PBD, because of procedure-related complications. Similar results were obtained with endoscopic PBD. Six meta-analyses have not clarified the role of PBD in the management of patients with malignant jaundice undergoing pancreaticoduodenectomy, because of lack of uniformity among all the studies published. Recently, the results of a large randomized controlled trial indicated that direct surgery should be the best therapeutic strategy for jaundiced patients with RPC. The debate whether jaundiced patients with RPC should undergo PBD continues and the advent of neoadjuvant chemoradiotherapy added some arguments in favor of PBD. The latter is still considered the first step for jaundiced patients when they present with cholangitis, intense pruritus or severe jaundice; surgery cannot be scheduled within 7-10 days from the diagnosis; neoadjuvant chemoradiation is planned, as part of the treatment. While endoscopic PBD is considered the preferred approach, there is still controversy about the type of biliary stent which should be used. Emerging data support the insertion of short (4-6 cm) biliary self-expandable metallic stent, especially if surgery is not immediately planned.

Metal stents for distal biliary malignancy: have we got you covered?

ObjectiveTo investigate whether preoperative biliary drainage is beneficial for patients undergoing pancreaticoduodenectomy.MethodsThe PubMed, Cochrane Library and the Web of Science were systematically searched for relevant trials that included outcome of pancreaticoduodenectomy with and without preoperative biliary drainage from January 2010 to May 2024. The primary outcomes are postoperative pancreatic fistula and intra-abdominal infection. Data is pooled using the risk ratio or standardized mean difference with 95% confidence interval. The study protocol was registered prospectively with PROSPERO (CRD42022372584).ResultsA total of 39 retrospective cohort studies with 33,516 patients were included in this trial. Compared with no preoperative biliary drainage, the preoperative biliary drainage group had a longer hospital stay (SMD, 0.14). Performing preoperative biliary drainage significantly increases the risk of postoperative pancreatic fistula (RR, 1.09), intra-abdominal infection (RR, 1.09), surgical site infection (RR, 1.84), and sepsis (RR, 1.37). But preoperative biliary drainage lowers risk of bile leak (RR, 0.74).ConclusionPreoperative biliary drainage before pancreaticoduodenectomy increases the risk of postoperative complications without clear overall benefits. Routine PBD is not recommended for younger patients with mild to moderate jaundice but may be considered for high-risk patients, such as those with severe infections or progressive jaundice. Optimizing preoperative biliary drainage duration and timing may help reduce complications. Further research is needed to refine patient selection and perioperative strategies.

Background: Pancreatic and hepatobiliary tumors continue to rank among the deadliest cancers worldwide. Due to a low response rate to treatment, these tumors continue to have a high death rate, a poor prognosis and survival rate, and an overall poor patient outcome. The multimodal strategy used in current treatment includes systemic therapy, radiation therapy, and surgery. However, surgery remains the only treatment with curative intent. Preoperative biliary drainage has a direct impact on the perioperative prognosis of patients with obstructive jaundice and significantly compromised liver function due to hepato-bilio-pancreatic malignancies. Our study’s goal was to determine the safest and most efficient preoperative biliary drainage technique by conducting a systematic review and meta-analysis of resectable periampullary cancers. Methods: Our approach consisted of searching PubMed, BMC Medicine, and Scopus databases using keywords with a result of 1104 articles from 2010 to 2023. The remaining 24 articles that met our inclusion criteria were subjected to meta-analysis using R Commander 4.3.2. Results: Endoscopic retrograde biliary drainage (ERBD) demonstrated a higher rate of postprocedural pancreatitis (RR = 2.22, p < 0.01), intra-abdominal abscess (RR = 1.64, p < 0.01), and delayed gastric emptying (DGE) (RR = 2.07, p < 0.01) than percutaneous transhepatic biliary drainage (PTBD) or endoscopic nasobiliary drainage (ENBD). Plastic stent (PS) had higher rates of catheter occlusion (RR = 2.20, p < 0.01) and POPF (RR = 1.66, p < 0.01) compared to self-expandable metallic stent (SEMS), which could explain a longer hospital stay (MD = 2.41 days, p < 0.01). However, PS had lower rates of grade 1–2 complications (RR = 0.79, p = 0.017) and wound infection rates (RR = 0.66, p = 0.017) than self-expandable metallic stent (SEMS). Conclusions: The choice of a preoperative drainage method can influence postprocedural and postoperative complications rates. ERBD appears to be associated with higher procedure-related and postoperative complication rates and may be linked to a prolonged hospital stay compared to ENBD or PTBD. Moreover, the type of stent placed through ERBD procedure had an important impact on prognosis, as PS had a higher rate of catheter occlusion and POPF, with a prolonged hospital stay compared to SEMS, while mild complications and wound infections were less common in PS group.