Unnecessary preoperative biliary drainage: impact on perioperative outcomes of resectable periampullary tumors

Routine preoperative endoscopic biliary drainage (PEBD) is not recommended for malignant periampullary tumors (MPT) with uncomplicated obstructive cholestasis, yet many patients still receive routine PEBD. Herein were assessed perioperative outcomes of routine PEBD in resectable MPT with uncomplicated biliary obstruction. From 2008 to 2014, we identified three groups among patients undergoing surgery for resectable MPT: unnecessary-PEBD (despite recommendations), necessary-PEBD (following recommendations), and upfront-surgery groups. The first two groups were compared on referral patterns, drainage procedure, and post-PEBD complications; Unnecessary-PEBD and upfront-surgery groups were compared on perioperative outcomes. A total 140 patients underwent surgery for resectable MPT; 38 had cholestasis with clear PEBD indication (necessary-PEBD). A further 66 presented uncomplicated obstructive cholestasis with total bilirubin < 300 mu mol/l, of whom 26 had unnecessary PEBD and 40 underwent upfront surgery. In total, 40.1% of PEBD were unnecessary and 64.1% were performed before surgical consultation. Time-to-surgery was significantly increased in the unnecessary-PEBD group by a mean +/- SD 35.3 +/- 5.5 days as compared to upfront-surgery group (95%CI [24.4-46.2]; p < 0.001). The unnecessary-PEBD group had a post-PEBD complication rate of 34.6%, and 7.7% were unresectable due to severe fibrosis following PEBD-induced acute pancreatitis. Perioperative severe complication rate was higher in the unnecessary-PEBD (73.1%) than in the upfront-surgery group (37.5%, p = 0.005), as was Clavien-Dindo grade > II post-operative complication rate (65.4 and 37.5%; p = 0.03). Routine preoperative biliary drainage is associated with an increased morbidity and persists despite recommendations against its systematic use. Early multidisciplinary team discussions with pancreatic surgeons should be implemented with an aim to reduce unnecessary stenting and improve patient outcomes.