Quintus Molenaar

Evaluation of Preoperative Biliary Drainage in Patients Undergoing Pancreatoduodenectomy For Suspected Pancreatic or Periampullary Cancer

Introduction A Dutch randomized trial showed that patients with obstructive jaundice due to periampullary tumors and a bilirubin below 250 μmol/l have a higher rate of complications after preoperative biliary drainage as compared to early surgery. Therefore, in the Netherlands the recommended treatment is early surgery without preoperative biliary drainage. This study investigated adherence to this recommendation. Methods A retrospective multicenter cohort study was performed in patients undergoing pancreatoduodenectomy for suspected malignancy in a 2-years period in seven Dutch high-volume centers. The proportion of and reasons for preoperative biliary drainage were studied. Results Pancreatoduodenectomy was performed in 609 patients, of whom 401 (66%) presented with preoperative jaundice. Of these, 245 patients had bilirubin levels below 250 μmol/l. Preoperative biliary drainage was performed in 165 (67%) of these patients. In the majority of patients, no medical reason justifying a preoperative biliary drainage could be retrieved from the medical charts (n=102, 62%). Preoperative biliary drainage was mostly performed in the hospital of diagnosis prior to referral to a pancreatic center (53%). After referral, the rate of preoperative biliary drainage varied considerably between pancreatic centers (13% - 58%, p<0.001). Conclusion In the Netherlands, more than half of the patients with obstructive jaundice still undergo preoperative biliary drainage prior to surgery in the Netherlands without an urgent medical reason. Given the negative influence of preoperative biliary drainage on outcome, this practice should be improved.