Endoscopic and percutaneous biliary drainage procedures: Role in preoperative management, diagnosis, and palliation

Abstract

Most patients with pancreatic cancer develop obstructive jaundice. Management of malignant biliary obstruction is dependent upon factors such as certainty of the diagnosis, symptoms, and resectability status of the patient. Tissue sampling during endoscopic retrograde cholangiopancreatography (ERCP) has a relatively low sensitivity but high specificity. Surgical resection is the only potentially curative treatment option. Patients with obstructive jaundice have various pathophysiological changes that affect the liver, kidney, heart, and the immune system, potentially increasing the risk of postoperative complications following pancreaticoduodenectomy. However, the role of routine preoperative biliary drainage (PBD) in the management of jaundiced patients with resectable pancreatic cancer is controversial. Most clinical studies have failed to show a clear advantage for patients undergoing PBD and have advised against routinely performing these procedures. PBD appears to increase overall morbidity because of procedure-related complications, especially if plastic stents are used for biliary decompression. Self-expandable metal stents (SEMS) have a longer patency and could reduce the risk of stent-related complications due to early occlusion. PBD may be beneficial in selected patients including those with cholangitis, when surgery is delayed, or when neoadjuvant therapy is planned. ERCP with placement of a short SEMS is the preferred modality and does not interfere with subsequent pancreaticoduodenectomy. Percutaneous and EUS-guided biliary drainage procedures are useful alternatives when ERCP is unsuccessful. SEMS placement is useful as palliation for patients with unresectable disease.