The role of preoperative biliary drainage in severely jaundiced patients.

Abstract

To the editor, We read with interest the article entitled ‘‘Preoperative Biliary Drainage of Severely Jaundiced Patients Increases Morbidity of Pancreaticoduodenectomy: Results of a CaseControl Study [1]’’ published recently in the World Journal of Surgery. The authors claim that no preoperative biliary drainage (PBD) was associated with a lower complication rate and a shorter hospital stay. However, we have some questions about the study. First, the authors defined severely jaundiced as a preoperative serum bilirubin C15 mg/dl ‘‘for ensuring the number of patients incorporated in study adequate for credible statistical analysis.’’ This criterion can not be commonly applied, which limits the value of this study. Second, the article claims that the morbidity rate in the no PBD group (24 %) was significantly lower than the PBD group (36 %). However, the morbidity rate in the no PBD group was also much lower than has been previously reported in high-volume centers (40–60 %) (incorrectly cited in their article) as mentioned in their ‘‘Introduction.’’ Did other factors exist in the no PBD group that contributed to the lowered complication rate, such as the selection criterion of the patients from the overall 240 patients? Additionally, the authors provided completely different morbidity rates in their ‘‘Results’’ Section (24 vs. 36 %) and Table 2 (25 vs. 42 %). Third, shorter hospitalization (11 vs. 16 days) was reported for the no PBD group due to the lower complication rate. However, the patients in the PBD group also received 2–4 weeks of biliary drainage prior to pancreaticoduodenectomy, which could contribute to the long hospital stay in the PBD group. In addition, the PBD median time was reported to be 40 days but the time range was reported to be 2–4 weeks. The hospital stay was reported to be only 16 ± 8 days in spite of the 2–4 weeks for PBD. Last, a similar study was performed in our institution. The 2 groups were similar in terms of demographics, perioperative, and pathological results (data not shown). However, the morbidity rate was not significantly different (P [ 0.05) (Table 1). Although the overall hospital stay was longer in the PBD group (P \ 0.01), the postoperative hospital stay was comparable between the 2 groups (P [ 0.05) (Table 1). This result implies that the longer hospital stay in the PBD group may be attributed to the time spent on preoperative biliary drainage but not because of a higher complication rate.