Preoperative biliary drainage for distal obstruction: the case against revisited

Abstract

OBJECTIVES: No conclusive evidence exists confirming the role of preoperative biliary drainage (PBD) in reversing the physiological disturbances resulting from biliary obstruction to improve outcome. This review examined the impact of PBD and the outcomes after surgery. METHODS: A PubMed literature search was undertaken using the keywords preoperative, biliary, and drainage. The primary end points were the effect of PBD on mortality, morbidity, and bile cultures. The secondary outcome measures were PBD and pancreatic leakage, intra-abdominal abscess, sepsis/infectious complications, wound infection, hemorrhage, and bile leak rates. The impact of bile cultures positive for bacteria and the outcomes after surgery were also examined. RESULTS: Preoperative biliary drainage significantly increases wound and bile infection rates on meta-analysis (P < 0.0005) using a fixed and random effect model, but no adverse effect on mortality and morbidity was found. A bile culture positive for bacteria negatively impacts on both mortality and morbidity (P < 0.005) after surgery. CONCLUSIONS: Preoperative biliary drainage significantly increases the rates of bile culture positive for bacteria and the probability of wound infection. Bile cultures positive for bacteria adversely impact mortality and morbidity after surgery in jaundiced patients. Although no evidence has been found by this review that PBD directly increases mortality and morbidity, it is possible that in certain patients, PBD may deleteriously affect outcome by bacterial contamination of the bile.