Data Review:
PBD is commonly utilized in the management of patients with obstructive jaundice from
periampullary malignancy. Multiple retrospective studies have reported an increase in overall
complications, and more often infectious complications in patients who undergo PBD compared
to patients taken for resection without drainage.1-6 Clearly there are biases to retrospective
studies, which fuels the argument for routine PBD. However a recent multi-institution,
prospective randomized controlled trial evaluated PBD in patients with pancreatic
adenocarcinoma and found that PBD increases complications without providing any obvious
benefit to patients.7 Despite these data, PBD continues to be highly utilized, and a recent review
of SEER data showed that the rate of PBD is increasing in the United States.8
There are some clinical scenarios where PBD is clearly indicated: the need for neoadjuvant
therapy, the presence of sequelae from prolonged obstruction such as coagulopathy or renal
failure, or significant symptoms of pruritus and the patient cannot be taken to the operating room
in a timely fashion. A replaced right hepatic artery is a relative indication for PBD due to the
fact that jaundiced patients do not tolerate loss of arterial hepatic flow since there is bile duct
dilatation and venous compression. Therefore these patients are at risk for hepatic abscess and
should be drained if the artery appears to be in a position where it would require resection. In
sum, there are data to at least support selective drainage rather than routine drainage in patients
with obstructive jaundice. We look forward to your comments and input as to how you would
have managed this case.
References:
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Heslin MJ, Brooks AD, Hochwald SN, Harrison LE, Blumgart LH, Brennan MF. A
preoperative biliary stent is associated with increased complications after
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Mann CD, Palser T, Briggs CD, et al. A review of factors predicting perioperative death
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Mezhir JJ, Brennan MF, Baser RE, et al. A matched case-control study of preoperative
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Povoski SP, Karpeh MS, Jr., Conlon KC, Blumgart LH, Brennan MF. Association of
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Ann Surg 1999;230:131-42.
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van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for
cancer of the head of the pancreas. N Engl J Med 2010;362:129-37.
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Jinkins LJ, Parmar AD, Han Y, Duncan CB, Sheffield KM, Brown KM, Riall TS.
Current trends in preoperative biliary stenting in patients with pancreatic cancer. Surgery
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