Preoperative drainage for malignant biliary strictures: is it time for self-expanding metallic stents?

Palliation of jaundice improves the general health of the patient and, therefore, surgical outcomes. Because of the complexity and location of strictures, especially proximally, drainage has been accompanied by increased morbidity due to sepsis. Another concern is the provocation of an inflammatory and fibrotic reaction around the area of stent placement. Preoperative biliary drainage with self-expanding metallic stent (SEMS) insertion can be achieved via a percutaneous method or through endoscopic retrograde cholangiopancreatography. A recently published multicenter randomized Dutch study has shown increased morbidity with preoperative biliary drainage. A Cochrane meta-analysis has also shown a significantly increased complication rate with preoperative drainage. However, few of these studies have used a SEMS, which allows better biliary drainage. No randomized controlled trials have compared preoperative deployment of SEMS versus conventional plastic stents. The outcomes of biliary drainage also depend on the location of the obstruction, namely the difficulty with proximal compared to distal strictures. Pathophysiologically, palliation of jaundice will benefit all patients awaiting surgery. However, preoperative drainage often results in increased morbidity because of procedure-related sepsis. The use of SEMS may change the outcome of preoperative biliary drainage dramatically.