K. Mahendraraj1, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada
Introduction:
Preoperative biliary drainage (PBD) was initially introduced to improve the postoperative outcome in patients with obstructive jaundice caused by pancreatic head and periampullary tumors, yet its benefits remain uncertain.This meta-analysis aimed to assess the benefits and risks of routine PBD in patients with obstructive jaundice compared to immediate surgery.
Methods:
A comprehensive search of PUBMED, Embase, and both the Cochrane and NIH Registry of Clinical Trials was conducted using the keywords ‘preoperative biliary drainage’, ‘obstructive jaundice’ and ‘randomized controlled trial (RCT)’. Citations of relevant review articles were examined. 25 potentially eligible studies were identified, of which 18 were excluded for lack of randomization, inadequate blinding and incomplete outcome data. Only RCTs which were completed and analyzed as level 1 studies were included. Data on patient recruitment, intervention and complications were extracted from the included trials and analyzed. ‘Overall’ complications were defined as those associated with PBD (including pancreatitis, bleeding and bowel perforation) in addition to postoperative complications (which included reoperation, readmissions, technical, infectious and hepatobiliary complications). The risk ratio (RR) was calculated with 95% confidence intervals.
Results:
7 RCTs involving 548 patients with obstructive jaundice were analyzed. 279 patients (50.9%) were randomized to receive PBD while 269 patients (49.1%) proceeded directly to surgery. Overall morbidity was 30% higher in the PBD group, although this difference was not statistically significant (RR 1.3, 95% CI 0.97-1.75; p=0.08). Overall postoperative morbidity was 6% lower with PBD, but not statistically significant (RR 0.94, 95% CI 0.74-1.20; p=0.62). Overall mortality was 10% higher in the preoperative biliary drainage group, but this finding was not significant (RR 1.1, 95% CI 0.72-1.68; p=0.65). Significant heterogeneity was found among the identified trials with regard to the definition and severity of complications, as well as the precise timing of PBD.
Conclusion:
The routine use of PBD in patients with obstructive jaundice did not significantly reduce overall complication rates or perioperative mortality. Current evidence suggests routine PBD does not improve patient outcomes. Further clarification of the effects of PBD is required in large, adequately powered randomized trials with low risk of bias.
