To drain or not to drain

The most common presenting symptom for someone with pancreatic head cancer is painless progressive jaundice. The prognosis for inoperable pancreatic cancer is grave. Surgical resection is the only curative options. For those jaundiced patients with operable pancreatic cancer, some clinicians will insist on relieving the jaundice before surgery. This is achieved by placing a plastic stent into the common bile duct to re-establish bile flow into the duodenum. Usually this means a delay of 4 to 6 weeks before surgery can be performed. (The rationale for relieving the jaundice is to reduce the risk of developing hepato-renal syndrome.)  However, some surgeons will operate immediately without relieving the jaundice, believing that stenting before surgery increases the post-operative complications rate. The argument of ‘to drain or not to drain’ before surgery has been raging for more than 2 decades.

A multi-centre, randomised study on 202 patients with pancreatic head cancer was recently completed in the Netherlands (N Engl J Med 2010; 362: 129 – 137). The researchers compared pre-operative biliary drainage (for 4 – 6 weeks) with subsequent surgery against surgery alone in order to determine the rate of serious complications within 120 days after randomization in these 2 groups of patients. The rate of serious complications in the early surgery group was 39% while that in the biliary drainage group was 74%. The surgery-related complications rate was 37% in the early surgery group compared to 47% in the biliary drainage group. This study thus showed that routine pre-operative biliary drainage increases the rate of complications in patients with jaundice secondary to pancreatic head cancer.

Despite this study, there will still be clinicians who routinely perform pre-operative biliary drainage for these patients because they believe this will reduce the risks associated with surgery in the presence of jaundice. As it is very difficult to complete a study with very large number of patients with pancreatic head cancer, the controversy of ‘drainage’ versus ‘no drainage’ will unfortunately continue.