Efficacy and safety of preoperative biliary drainage in patients undergoing pancreaticoduodenectomy: an updated systematic review and meta-analysis

This study aimed to evaluate the effect of preoperative biliary drainage (PBD) on outcomes of pancreaticoduodenectomy (PD) in patients with biliary obstruction.
We searched PubMed, EMBASE, Cochrane library, and Web of Science from database inception to 11 March 2021. We used the ROBINS-I tool and Cochrane risk of bias tool 2.0 to assess the risk of bias. The data were statistically analyzed using the RevMan software (Version 5.4).
In all, 43 studies, including 23,076 patients, were analyzed, of which 13,922 patients were treated with PBD and 9154 were treated with no preoperative biliary drainage (NPBD). The morbidity, infection morbidity, and postoperative pancreatic fistulae (POPF) in patients undergoing PBD, were significantly higher than those in patients undergoing NPBD. Further, PBD may lead to a significantly worse 2- and 3-year overall survival (OS) rates. In subgroup meta-analysis, the differences in morbidity, POPF, and OS outcomes lost significance between the PBD and NPBD groups when the mean total serum bilirubin (TSB) concentration was below 15 mg/dl.
Routine PBD still cannot be recommended because it showed no beneficial effect on postoperative outcomes. However, in patients with < 15 mg/dl TSB concentration, PBD tends to be a better choice.

本研究旨在评估术前胆道引流（preoperative biliary drainage, PBD）对胆道梗阻患者行胰十二指肠切除术（pancreaticoduodenectomy, PD）后的预后影响。
本研究检索了PubMed、EMBASE、Cochrane图书馆及Web of Science自建库至2021年3月11日的相关文献，采用ROBINS-I工具与Cochrane偏倚风险评估工具2.0对纳入研究的偏倚风险进行评估，并使用RevMan软件（版本5.4）完成统计学分析。
最终共纳入43项研究，涉及23076例患者，其中13922例接受术前胆道引流治疗，9154例接受术前无胆道引流（no preoperative biliary drainage, NPBD）治疗。结果显示，接受PBD的患者其术后总体并发症发生率、感染并发症发生率及术后胰瘘（postoperative pancreatic fistulae, POPF）发生率均显著高于NPBD组；此外，PBD可能会导致患者2年及3年总生存率（overall survival, OS）显著降低。亚组Meta分析结果表明，当患者血清总胆红素（total serum bilirubin, TSB）平均浓度低于15 mg/dl时，PBD组与NPBD组在并发症发生率、术后胰瘘发生率及总生存率方面的差异不再具有统计学意义。
目前仍不推荐常规实施术前胆道引流，因其未对术后预后产生获益；但对于血清总胆红素浓度低于15 mg/dl的患者，术前胆道引流或许是更优的选择。