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Updated: Aug 1, 2026
Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction
Published on: March 25, 2022
Is preoperative biliary drainage necessary according to evidence-based medicine?
1First Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
Insights
Preoperative biliary drainage is not medically necessary for lower bile duct obstruction, according to recent trials. Further randomized controlled trials are needed to clarify its role in upper bile duct obstructions.
Area of Science:
- Gastroenterology and Hepatology
- Interventional Radiology
- Surgical Oncology
Background:
- Preoperative biliary drainage has been a long-standing practice, but its medical necessity is increasingly questioned.
- Historically, challenges in diagnosing obstructive jaundice and surgical limitations contributed to its use.
- Advancements in medical technology and evidence-based medicine are prompting a re-evaluation of its routine application.
Purpose of the Study:
- To critically assess the established necessity of preoperative biliary drainage in managing obstructive jaundice.
- To review current evidence regarding the efficacy and indications of preoperative biliary drainage.
- To differentiate the role of preoperative biliary drainage in lower versus upper bile duct obstructions.
Main Methods:
- Review of recent controlled trials and existing literature on preoperative biliary drainage.
- Analysis of evidence supporting or refuting the routine use of biliary drainage before surgery.
- Examination of the utility of percutaneous transhepatic cholangial drainage (PTCD) and percutaneous transhepatic cholangioscopy (PTCS).
Main Results:
- Recent controlled trials indicate preoperative biliary drainage is unnecessary for lower bile duct obstruction.
- Surgery is facilitated after jaundice reduction via percutaneous transhepatic cholangial drainage (PTCD).
- The necessity for upper bile duct obstruction (e.g., hilar cholangiocarcinoma) requires further clarification through randomized controlled trials.
Conclusions:
- Preoperative biliary drainage is not a mandatory procedure for lower bile duct obstruction, regardless of technique (percutaneous, endoscopic, stenting).
- Biliary drainage and stenting are crucial for gallstone removal, acute cholangitis management, and treating unresectable malignant biliary stenosis.
- Percutaneous transhepatic cholangioscopy (PTCS) is valuable for stone removal and differentiating benign from malignant biliary lesions.
Abstract:
Preoperative biliary drainage has been in use for a long time and is still being performed today in some institutions, but there has been a long-standing issue as to whether the necessity of this procedure has been proven medically. Many problems existed previously, such as systemic complications due to the difficulty in diagnosing and differentiating obstructive jaundice from jaundice left untreated for a long time, or surgeon-based problems such as a lack of surgical skill or undeveloped surgical techniques, or even inexperience in perioperative patient management. These problems, however, are being overcome with time, and the advantages of preoperative biliary drainage are now being questioned according to evidence-based medicine. Several recent controlled trials have clearly shown that preoperative biliary drainage is not necessary for lower bile duct obstruction, although it was noted that surgery after reduction of jaundice by percutaneous transhepatic cholangial drainage (PTCD) was very easily performed. It is important to understand that preoperative biliary drainage is unnecessary for lower bile duct obstruction, whether the technique follows a percutaneous approach, an endoscopic apporach, or stenting. Although it is still being debated, there have already been several reports regarding whether preoperative biliary drainage is necessary for upper bile duct obstruction, such as hilar bile duct carcinoma. This also needs to be clarified by randomized controlled trials. Aside from preoperative biliary drainage, the utilization of biliary drainage or stenting has been fully recognized as important for removing intrahepatic stones or choledochal stones, as well as for emergency drainage for acute cholangitis and for the treatment of unresectable malignant biliary stenosis. Additionally, percutaneous transhepatic cholangioscopy (PTCS), using the PTCD. or percutaneous transhepatic biliary drainage (PTBD) route. plays a major role not only in the removal of biliary stones but also in the diagnosis of cases in which it is difficult to differentiate between benign and malignant lesions.
