Is preoperative endoscopic biliary drainage indicated for jaundiced patients with resectable pancreatic cancer?

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.