A Meta-analysis on the Efficacy of Preoperative Biliary Drainage for Tumors Causing Obstructive Jaundice

Surgery in jaundiced patients with tumors carries an increased risk of postoperative complications. 1,2 Several risk factors have been identified; among these, preoperative hyperbilirubinemia has been identified as a potential risk factor for poor outcome. 3–5 To avoid death and complications, preoperative biliary drainage (PBD) has been proposed as a means of reversing the pathophysiologic disturbances seen in jaundiced patients. In 1935, Whipple already had performed a staged surgical approach with a preliminary bypass to reduce jaundice and improve hepatic function. 6 Interest in the staged approach was renewed with the advent of a nonoperative first stage, external and later internal biliary drainage. In the late 1970s, the first studies on PBD reported a reduced postoperative death rate in jaundiced patients. 7,8 Since then, numerous studies, randomized as well as retrospective, have compared the outcome of PBD with surgery without PBD. Studies in experimental animals have shown benefit of PBD, especially after internal drainage when the enterohepatic circulation was restored. 9,10 Clinical studies have failed to show this benefit, and some studies even reported a deleterious effect. 11–17 Despite the lack of a beneficial effect in many centers, most jaundiced patients undergo surgery for tumors after preoperative drainage. PBD is mainly performed because of logistic problems, such as time needed for further staging and the expected waiting time for surgery. The objective of this meta-analysis was to examine the effectiveness of PBD in jaundiced patients with tumors, to guide clinicians in their management of these patients, and to identify areas of uncertainty for future research.