Preoperative biliary drainage versus upfront surgery in moderately jaundiced patients undergoing
Kaushal Singh Rathore1, Gaurav Kaushal1
1Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, India.
Insights
For patients with moderate jaundice undergoing pancreaticoduodenectomy, upfront surgery is safe and avoids complications. Preoperative biliary drainage does not improve outcomes and increases infection risks and costs.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Hepatobiliary Surgery
Background:
- The role of preoperative biliary drainage (PBD) in pancreaticoduodenectomy (PD) for patients with moderate jaundice (10-15 mg/dL) is not well-established.
- While PBD aims to enhance liver function, it may lead to increased morbidity due to infections.
Purpose of the Study:
- To compare the outcomes of upfront PD versus PBD in patients with moderate jaundice and periampullary cancers.
- To evaluate perioperative outcomes, morbidity, mortality, bile microbiology, antibiotic use, and costs.
Main Methods:
- Retrospective analysis of PD patients with periampullary cancers and bilirubin levels of 10-15 mg/dL (July 2022-2025).
- Comparison between upfront surgery (UP) group and PBD group (endoscopic retrograde cholangiopancreatography or percutaneous transhepatic biliary drainage).
Main Results:
- 40 patients met inclusion criteria (UP=16, PBD=24).
- The PBD group had higher surgical site infections (70.8% vs. 18.7%), positive bile cultures (75% vs. 25%), and antibiotic costs (+50%).
- Overall morbidity, severe complications, and 90-day mortality were similar between groups.
Conclusions:
- Upfront PD is a safe option for patients with moderate jaundice (10-15 mg/dL).
- Routine PBD provides no clinical benefit and is linked to increased SSIs, bile contamination, and higher costs.
Backgrounds/Aims:
The effect of preoperative biliary drainage (PBD) on outcomes for pancreaticoduodenectomy (PD) patients with moderate jaundice (10-15 mg/dL) remains understudied. While PBD aims to improve hepatic function, it may increase morbidity due to infections.
Methods:
This study analyzed PDs performed between July 2022 and 2025. Patients with periampullary cancers and bilirubin levels of 10-15 mg/dL were included. We compared patients who underwent upfront PD (upfront surgery [UP] group) with those who received PBD (via endoscopic retrograde cholangiopancreatography or percutaneous transhepatic biliary drainage) regarding perioperative outcomes, morbidity, mortality, bile microbiology, antibiotic use, and costs.
Results:
Among 92 PD patients, 40 met the inclusion criteria (UP = 16; PBD = 24). Baseline characteristics were comparable, except for higher bilirubin levels in the UP group (12.6 mg/dL vs. 1.35 mg/dL, p = 0.001). The PBD group exhibited a harder pancreatic texture (58.3% vs. 25.0%, p = 0.03), higher surgical site infections (SSIs) (70.8% vs. 18.7%, p = 0.001), and a greater incidence of positive bile cultures (75% vs. 25.0%, p = 0.001). Overall morbidity, Clavien-Dindo grade 3 complications, and 90-day mortality rates were similar between the groups. However, antibiotic costs were significantly higher in the PBD group (₹31,047 vs. ₹20,937; + 50%).
Conclusions:
In patients with moderate jaundice (10-15 mg/dL), upfront PD can be performed safely. Routine PBD offers no clinical benefit and is associated with higher rates of SSIs, bile contamination, and increased costs.
