Preoperative Biliary Drainage for Pancreatic Cancer and Cholangiocarcinoma

Routine preoperative biliary drainage (PBD) for malignant distal biliary obstruction is not recommended in cases undergoing upfront surgery due to the lack of advantage in PBD. However, PBD is still performed in clinical practice because early surgery is not always possible and biliary drainage is necessary in cases with concomitant cholangitis or in cases undergoing neoadjuvant chemo(radiation) therapy (NAC). While a self-expandable metallic stent (SEMS) appears to provide better stent patency than a plastic stent (PS), there are still some concerns about the use of SEMS as PBD because of possible inflammation along the bile duct. Hilar cholangiocarcinoma (HCCA) often invades the common hepatic duct and the confluence of the left and right hepatic ducts. The growth of tumors in porta hepatis can easily cause obstructive jaundice. PBD can relieve obstruction, reduce symptoms of cholangitis, and correct severe malnutrition. Techniques of PBD include endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD). EBD was often associated with stent occlusion and retrograde infection of the bile duct. Bacterial contamination caused by EBD may induce preoperative cholangitis, which is considered to be an independent risk factor in surgical resection.