Review for 10.1186/s12876-025-03761-x (2025)

Title: Whether preoperative biliary drainage leads to better patient outcomes of
pancreaticoduodenectomy: A meta-analysis and systematic review
Version: 1 Date: 15 Jan 2025
Reviewer:  Omar J. Shah
Reviewer's report:
Obstructive jaundice is the most common feature in patients with pancreatic head or
periampullary tumors which  leads to changes in hepatic function, coagulation, and fibrinolysis.
Prolonged and progressive cholestasis increases the risk of cholangitis, hepatic failure, and may
affect surgical outcomes
Data over the past decade demonstrates increased perioperative complications and with higher
morbidity with systematic PBD compared to direct surgery. With new evidence of potential
adverse events, the role of routine PBD is being reassessed. Current indications for PBD
may  include cholangitis, delayed surgery, and relief of jaundice in patients planned to receive
neoadjuvant  therapy in borderline   resectable lesions.
Several retrospective analyses have shown no improvement in overall morbidity between
patients receiving PBD and those who did not. In fact, PBD was associated
with increased operative time, intraoperative blood loss, and incidence of postoperative
infections
Zhang et al have presented a systemic review and a meta-analysis on:
Whether preoperative biliary drainage leads to better patient outcomes of
pancreaticoduodenectomy.  Based   on  selected 39 studies, a longer hospital stay with increase
in postoperative pancreatic fistula , infective complications and sepsis rates were observed with
the preoperative biliary drainage patients. However, postoperative rates of biliary fistulas were
less in no-preoperative biliary drainage group.
Inclusion criteria:
The patient is generally in good condition and older than 18 years. This needs to be explained.
The Inclusion and Exclusion criteria are not clearly understood. This sections needs to be
relooked and clearly reproduced.
The authors conclude that: Actively performing preoperative biliary drainage before
pancreaticoduodenectomy does not bring obvious benefits to patients, but instead increases
the risk of postoperative complications and prolongs recovery time. However, personalized
treatment is still needed for people who are at risk of biliary fistula after surgery and those who
are over 65 years old.
Aggressive PBD before PD does not tend to bring additional benefits to patients, although PBD
may reduce the risk of postoperative biliary fistulas. On the contrary, PBD prolongs the patient's
recovery time and increases the risk of postoperative pancreatic fistula, sepsis, and infection.
PBD should be performed based on indications and contraindications and individualized
treatment. Routine PBD is not recommended for patients under 65 years old with mild or
moderate jaundice without other obvious discomfort. However, PBD can be considered for
patients over 65 years old with severe infection, progressive jaundice and risk of postoperative
biliary fistulas.
Several retrospective analyses have shown no improvement in overall morbidity between
patients receiving PBD and those who did not. In fact, PBD was associated with increased
operative time, intraoperative blood loss, and incidence of postoperative infections.
It might be appropriate to look into duration of PBD (drainage period and lower complication
rate). A shorter drainage period may be associated with a lower complication rate when
compared with a longer drainage period.
There are reports of   robotic PD, along with a suitable extension of the interval between PBD and
PD, which appear to confer advantages concerning patients’ physiological recuperation. These
observations suggest potential strategies that may contribute to enhanced patient outcomes.
PBD has been found to be significantly associated with an increased risk of extended
hospitilazation, like the increase in   postoperative period, and postoperative transfer of
patient to ICU. Considering the patient’s economic and clinical factors, recommendations for
implementing robotic-assisted PD and extending PBD-PD interval could potentially contribute
to reducing the incidence of postoperative  infective  complications.
Though the authors have made a good attempt to produce a rational research paper on a difficult
subject with nice tables, unfortunately the message is not clearly depicted for the readers.
I suggest, for rewriting the paper under proper broad headings which at the conclusion should
lay down proper guidelines for a reader. The language issue needs attention.
Statistical work  must be examined by an expert in the field.