Preoperative biliary drainage for obstructive jaundice
Abstract
Background
Obstruction in the biliary drainage system causes a rise in serum bilirubin levels (obstructive jaundice). Studies have shown that surgery for severe obstructive jaundice is associated with high peri‐operative mortality and morbidity. Jaundice has been considered as a potential risk factor for poor outcome, and pre‐operative biliary drainage has been proposed as a method of reversing the pathophysiologic disturbance seen in patients with obstructive jaundice.
Objectives
To determine the benefits and harms of pre‐operative biliary drainage (ie, endoscopic sphincterotomy with stent insertion or percutaneous transhepatic biliary drainage) in obstructive jaundice.
Search methods
We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register (CHBG), the Cochrane Central Register of Controlled Clinical Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, the Chinese BioMedical Literature on disc (CBM disc), and the Chinese Medical Current Contents (CMCC). All databases were searched up to October 2006.
Selection criteria
We considered for inclusion randomised clinical trials comparing biliary drainage followed by surgery and direct surgery performed for obstructive jaundice.
Data collection and analysis
We collected the available data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, and hospital stay as reported in each trial. We analysed the data with both the fixed‐effect and the random‐effects models, using RevMan Analysis. For each outcome, we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention‐to‐treat analysis.
Main results
Five trials with 320 patients (160 in each group) were included. Four trials (n = 235) compared percutaneous transhepatic biliary drainage with direct surgery, and one trial (n = 85) compared pre‐operative endoscopic drainage with direct surgery. All trials were of low methodological quality. There was no significant difference in mortality (OR 1.14, 95% CI 0.60 to 2.10) between the pre‐operative biliary drainage group and the direct surgery group. No significant difference was found in mortality (OR 1.16, 95% CI 0.56 to 2.41), overall morbidity (OR 1.35, 95%CI 0.48 to 3.83), and in different complications between the percutaneous transhepatic biliary drainage group and the direct surgery group. The trial comparing pre‐operative endoscopic drainage and direct surgery showed no significant difference in mortality (OR 1.09, 95% CI 0.32 to 3.68), but found higher morbidity in the endoscopic drainage group. The overall hospital stay was 8 to 17 days shorter in the direct surgery group.
Authors' conclusions
Our analyses neither supports nor refutes pre‐operative biliary drainage for patients with obstructive jaundice needing surgery. In some specific lesion site it may cause more complications. Pre‐operative biliary drainage also prolonged hospital stay and increased cost. However, the strength of evidence is low because of the poor quality of the included trials. More rigorously designed randomised clinical trials with larger sample size and advanced techniques and drugs are needed.
Plain language summary
Pre‐operative biliary drainage is not recommended in patients who need surgery for obstructive jaundice
Several illnesses can cause an obstruction in the bile drainage system of the liver (obstructive jaundice). The most profound symptom is an elevated level of bilirubin (the 'dye' in the gall) in the blood causing the patient to appear yellow in the skin and eyes. Pre‐operative biliary drainage is aimed at improving liver function of patients with obstructive jaundice. However, the potential benefit of pre‐operative biliary drainage has not been clearly established. This review is important because it is the first of its kind to evaluate whether the pre‐operative drainage is beneficial or not.
This review is based upon five trials with a total of 320 patients ‐ 160 in each group, treatment and control. The present review found no evidence of any benefit of biliary drainage before surgery in patients with obstructive jaundice. In addition, increased hospital stay due to pre‐operative biliary drainage adds to hospital costs. The bias risks of the included randomised trials were high and the total number of participants small. Therefore, systematic errors ('bias') and random errors ('play of chance') cannot be excluded. We need further trials on the topic. At present, biliary drainage before surgery in patients with obstructive jaundice cannot be recommended outside randomised clinical trials.
The trials this review is based upon are 7 to 14 years old, and for this reason alone further trials are needed. In the past decade, methodology of clinical trials has developed and new antibiotics have emerged. Today the outcome of a clinical trial might therefore be different.
