ORIGINAL ARTICLE

Impact of Preoperative Biliary Drainage on Surgical

Outcomes in Periampullary and Hilar Malignancy:
A Single-Center Experience
Yukiko Ito, MD, PhD,* Yousuke Nakai, MD, PhD,*w
Hiroyuki Isayama, MD, PhD,*w Takeshi Tsujino, MD, PhD,*w
Tsuyoshi Hamada, MD, PhD,*w Gyotane Umefune, MD,*w
Dai Akiyama, MD, PhD,*w Kaoru Takagi, MD,*w
Takeshi Takamoto, MD, PhD,z Takuya Hashimoto, MD, PhD,z
Ryo Nakata, MD, PhD,* Kazuhiko Koike, MD, PhD,w
and Masatoshi Makuuchi, MD, PhDz

In addition, it is dicult to schedule major pancreatobiliary

Abstract: The role of preoperative biliary drainage (PBD) for
periampullary and hilar malignancy is still controversial. We ret-
rospectively studied consecutive 144 patients (92 periampullary and
52 hilar malignancy) undergoing surgical resection to evaluate the
eects of PBD on surgical outcomes. The rate of PBD was 59%
and 56%, and postoperative complications developed in 27% and
19% in periampullary and hilar malignancy, respectively. Risk
factors for postoperative complications were overweight [odds
ratio (OR), 7.6] and depression (OR, 8.5) in distal malignancy and
American society of anesthesiologists score of 3 (OR, 6.6),
depression (OR, 13.8), and portal vein embolization (OR, 6.1) in
hilar malignancy. PBD was not associated with postoperative
complications but reinterventions for PBD were necessary in 43%
and 27% in distal and hilar biliary obstruction. In conclusion, PBD
in pancreatobiliary surgery was not associated with postoperative
complications, but the improvement of PBD is necessary given the
high rate of reinterventions.
surgery within 2 weeks in most of the high-volume cen-
ters3,4 and PBD is still performed in many centers including
ours, despite the possible risks for increased morbidity
including infectious complications. During PBD procedure,
tumor extension can be evaluated by cholangiogram and
intraductal ultrasonography and pathologic examinations
such as transpapillary biopsies or brushing cytology5 can be
performed. Moreover, neoadjuvant chemotherapy is
increasingly reported in pancreatic cancer,6 and PBD is
essential in those patients receiving neoadjuvant chemo-
therapy due to the prolonged time to surgery.
In this retrospective analysis, we tried to evaluate the
impact of PBD in patients with periampullary and hilar
malignancy by analyzing risk factors for postoperative
complications.

Key Words: obstructive jaundice, preoperative biliary drainage,

postoperative complication
(Surg Laparosc Endosc Percutan Tech 2016;26:150155)
T he role of preoperative biliary drainage (PBD) in
patients with distal or hilar malignant biliary obstruc-
tion has been a matter of debate for a long time.1 Although
PBD is performed to maintain liver function, it might
increase the risk of infectious complications. A randomized
controlled trial by van der Gaag et al2 concluded that
routine PBD should not be performed in patients with
obstructive jaundice by periampullary tumors because of
increased morbidity. However, in the clinical practice,
pancreatobiliary malignancy often develops in elderly
patients with comorbidity who needs preoperative workup.
Received for publication May 22, 2015; accepted December 21, 2015.
From the Departments of *Gastroenterology; zHepato-Biliary-Pan-
creatic-Transplantation Surgery, Japanese Red Cross Medical
Center; and wDepartment of Gastroenterology, Graduate School of
Medicine, The University of Tokyo, Tokyo, Japan.
The authors declare no conicts of interest.
Reprints: Yousuke Nakai, MD, PhD, Department of Gastro-
enterology, Japanese Red Cross Medical Center, 4-1-22 Hiroo
Shibuya-ku, Tokyo, Japan 150-8935 (e-mail: ynakai-tky@umin.
ac.jp).
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METHODS
Patients
This was a single-center retrospective analysis of con-
secutive patients who underwent surgical resection for
periampullary or hilar malignancy at Japan Red Cross
Medical Center Hospital between January 2010 and March
2014. Cases were extracted from inpatient database of
Department of Gastroenterology and Department of Sur-
gery at Japan Red Cross Medical Center. Data on patients
characteristics, PBD, surgery, and postoperative outcomes
were retrospectively studied. This study was approved by
the local ethical committee in accordance with the Decla-
ration of Helsinki.
PBD
The indication of PBD for obstructive jaundice dened
as total bilirubin level of Z3.0 mg/dL at the time of diag-
nosis was decided by discussion with surgeons based on the
imaging ndings, patients characteristics, and time sched-
ule of surgery.
Endoscopic biliary drainage was rst attempted if not
contraindicated. For distal malignant biliary obstruction,
biliary drainage was placed in the common bile duct. For
hilar malignant biliary obstruction, biliary drainage was
placed in the future remnant liver (FRL) after preproce-
dural discussion between surgeons and endoscopists. Either

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Surg Laparosc Endosc Percutan Tech  Volume 26, Number 2, April 2016 PBD in Pancreatobiliary Cancer

decreased by 50% or more within 7 days or normalized

TABLE 1. Patient Characteristics in Periampullary Malignancy within 30 days. Complications of PBD were dened
All PBD Non-PBD according to a lexicon for endoscopic adverse events.12
(N = 92) (N = 54) (N = 38) P Postoperative morbidity was graded according to the
Age (y) 70 (62-77) 70 (63-76) 69 (60-78) 0.748 Dindo-Clavien classication.13 Time to surgery was dened
Male 48 (52) 30 (56) 18 (47) 0.526 as days between the initial consultation to surgical resec-
ASA score tion, and time to discharge was dened as days between the
1 16 (18) 6 (11) 10 (26) 0.133 initial consultation to discharge after surgical resection.
2 63 (68) 41 (76) 22 (58) Heavy drinking was dened as Z110 g of alcohol con-
3 13 (14) 7 (13) 6 (16) sumption per day.
BMIZ25 12 (13) 6 (11) 6 (16) 0.543
Hypertension 32 (35) 18 (33) 14 (37) 0.825 Endpoints and Statistical Analyses
Diabetes 27 (29) 13 (24) 14 (37) 0.246 Primary endpoint of this analysis is risk factor analysis
Heavy 14 (15) 6 (11) 8 (21) 0.243 for postoperative complications (the Dindo-Clavien grade
drinking
Smokers 30 (33) 17 (31) 13 (34) 0.824
Z2) in periampullary and hilar biliary malignancy. Safety
Depression 8 (9) 4 (7) 4 (11) 0.713 and ecacy of PBD in periampullary and hilar biliary
Final diagnosis malignancy were evaluated as secondary outcomes. Rein-
Pancreatic 56 (61) 29 (54) 27 (71) 0.002 tervention-free period for endoscopic PBD was calculated
cancer using the Kaplan-Meier method and compared by a log-
Bile duct 16 (17) 14 (26) 2 (5) rank test. Surgery without reintervention for endoscopic
cancer PBD was censored. Time to surgery or time to discharge
Ampullary 13 (14) 10 (19) 3 (8) was also compared between patients with and without
cancer PBD.
Others 7 (8) 1 (2) 6 (16)
T.Bil at 1.5 (0.6-8.0) 7.5 (3.0-12.4) 0.6 (0.5-0.8) < 0.001
Continuous variables were expressed as medians with
diagnosis interquartile range (IQR) and compared by a Mann-
(mg/dL) Whitney U test. Either the w2 or the Fisher exact test was
T.Bil at 0.9 (0.6-1.5) 1.3 (0.8-2.4) 0.6 (0.4-0.8) < 0.001 used to compare the categorical variables. Exploratory
surgery
(mg/dL)
TABLE 2. Patient Characteristics in Hilar Malignancy
Numbers are expressed either as median (interquartile range) or n (%).
ASA indicates American society of anesthesiologists; BMI, body mass All PBD Non-PBD
index; PBD, preoperative biliary drainage; T.Bil, total bilirubin. (N = 52) (N = 29) (N = 23) P
Age (y) 69 (61-87) 71 (59-78) 67 (62-74) 0.384
Male 25 (48) 14 (48) 11 (48) 1.000
endoscopic nasobiliary drainage (ENBD) or endoscopic ASA score
biliary stent (EBS) was placed at the discretion of the 1 3 (6) 1 (3) 2 (9) 0.793
endoscopist. Percutaneous transhepatic biliary drainage 2 38 (73) 22 (76) 16 (70)
(PTBD) was performed when ERC failed or intrahepatic 3 11 (21) 6 (21) 5 (22)
bile duct was highly divided by hilar malignancy. BMIZ25 7 (14) 4 (14) 3 (13) 1.000
Hypertension 22 (42) 12 (41) 10 (44) 1.000
Surgery Diabetes 12 (23) 4 (14) 8 (35) 0.102
Heavy drinking 4 (8) 4 (14) 0 0.120
All patients underwent surgical resection at our hos- Smokers 11 (21) 5 (17) 6 (26) 0.507
pital with an average volume of over 200 cases of surgical Depression 5 (10) 2 (7) 3(13) 0.644
resection for pancreatobiliary or hepatic cancer per year. Final diagnosis
The standard surgical procedure for periampullary Bile duct 19 (37) 16 (55) 3 (13) 0.031
malignancy was pancreatoduodenectomy. In patients cancer
without pancreatic duct dilation and/or soft texture of the Gallbladder 20 (38) 4 (16) 16 (62)
pancreas, 2-stage pancreatojejunostomy was performed.7 cancer
In patients with hilar malignancy, either hepatopancreato- ICC 5 (10) 2 (8) 3 (12)
Others 8 (15) 7 (24) 1 (4)
duodenectomy or extended hepatectomy was performed Bismuth
based on disease extension. Portal vein embolization 1 4 (14)
(PVE) was performed if deemed necessary based on the 2 4 (14)
volumetry of FRL.810 3 13 (45)
During periprocedural (PBD and surgery) period, all 4 8 (28)
patients received prophylactic antibiotics of second-gen- Portal vein 23 (44) 13 (45) 10 (43) 1.000
eration cephalosporin unless prior bile culture showed embolization
microorganisms resistant to second-generation cepha- T.Bil at 1.2 (0.7-6.2) 6.1 (1.3-9.8) 0.7 (0.6-1.1) < 0.001
losporin. diagnosis
(mg/dL)
T.Bil at surgery 0.8 (0.6-1.5) 1.3 (0.7-1.8) 0.7 (0.5-0.9) 0.002
Definition (mg/dL)
Distal and hilar malignant biliary obstruction was
dened as malignant biliary obstruction Z2 and <2 cm Numbers are expressed either as median (interquartile range) or n (%).
ASA indicates American society of anesthesiologists; BMI, body mass
from the hilum, respectively. Hilar malignant biliary index; ICC, intrahepatic cholangiocarcinoma; PBD, preoperative biliary
obstruction was classied by the Bismuth classication.11 drainage; T.Bil, total bilirubin.
PBD was dened as eective when total bilirubin level

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Ito et al Surg Laparosc Endosc Percutan Tech  Volume 26, Number 2, April 2016

TABLE 3. Preoperative Biliary Drainage and its Complications in

Distal and Hilar Biliary Obstructions
n (%)
Distal Obstruction Hilar Obstruction
(N = 54) (N = 29)
Initial drainage
ENBD 20 (37) 19 (66)
EBS 29 (54) 7 (24)
PTBD 5 (9) 3 (10)
Eective PBD (%) 93 97
Complications after endoscopic PBD
Pancreatitis
All grades 6 (12) 6 (23)
Severe 1 1
Moderate 1 1
Mild 4 4
Cholangitis 11 (22) 2 (8) FIGURE 2. Kaplan-Meier analysis of reintervention-free period in
Cholecystitis 0 1 (4) patients receiving ENBD (broken line) and EBS (solid line) for hilar
Migration/dislocation 5 (10) 3 (12) biliary obstruction. ENBD was associated with longer reinter-
Reinterventions for 21 (43) 7 (27) vention-free period (P = 0.047). EBS indicates endoscopic biliary
endoscopic PBD stent; ENBD, endoscopic nasobiliary drainage.
Exchange from ENBD 3 (6) 1 (4)
to EBS malignancy are shown in Tables 1 and 2. PVE was per-
formed in 44% of hilar malignancy. The rate of PVE did
EBS indicates endoscopic biliary stent; ENBD, endoscopic nasobiliary not dier between PBD and no PBD groups.
drainage; PBD, preoperative biliary drainage; PTBD, percutaneous trans-
hepatic biliary drainage.

PBD and Complications

multivariate analyses to explore the risk factors for post-
operative complications were performed using logistic
regression analysis. Factors with P < 0.05 in the univariate
analysis were included in the multivariate analysis. A P-
value <0.05 was considered statistically signicant. All
statistical analysis was performed using JMP software
(version 10.0, SAS International Inc., Cary, NC).
RESULTS
PBD was performed in 54 patients (59%) for distal
malignant biliary obstruction by periampullary malignancy
and 29 patients (56%) for hilar malignant biliary obstruc-
tion by hilar malignancy (Table 3). Initial biliary drainage
was ENBD in 20, EBS in 29, and PTBD in 5 in distal
malignant biliary obstruction and ENBD in 19, EBS in 7,
and PTBD in 3 in hilar malignant biliary obstruction. PBD
was eective in 93% and 97% in distal and hilar malignant
biliary obstruction.

Patients TABLE 4. Surgery and Postoperative Complications in

A total of 144 patients, 92 with periampullary malig- Periampullary and Hilar Malignancy
nancy and 52 with hilar malignancy, underwent surgical
Periampullary
resection at Japan Red Cross Medical Center Hospital.
(N = 92) Hilar (N = 52)
Patients characteristics of periampullary and hilar
Extended
Surgery PD HPD Hepatectomy
n 92 15 37
Postoperative complications [n (%)]
Overall 25 (27) 4 (27) 6 (16)
Pancreatic juice 7 (8) 1 (7)
leakage
Delayed gastric 12 (13) 1 (3)
emptying
Cholangitis 4 (4) 1 (3)
Bile leak 2 (5)
Anastomotic 1 (1) 1 (7)
leakage
Anastomotic 1 (1) 1 (7)
stenosis
Bleeding 1 (1)
Pneumonia 2 (2)
Abscess 2 (2) 2 (5)
Pancreatic 1 (7)
FIGURE 1. Kaplan-Meier analysis of reintervention-free period in
necrosis
patients receiving ENBD (broken line) and EBS (solid line) for
distal biliary obstruction. There were no significant differences HPD indicates hepatopancreatoduodenectomy; PD, pancreato-
between ENBD and EBS (P = 0.969). EBS indicates endoscopic duodenectomy.
biliary stent; ENBD, endoscopic nasobiliary drainage.

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Surg Laparosc Endosc Percutan Tech  Volume 26, Number 2, April 2016 PBD in Pancreatobiliary Cancer

TABLE 5. Univariate Analyses for Postoperative Complications in TABLE 6. Univariate Analyses for Postoperative Complications in
Periampullary Malignancy Hilar Malignancy
Incidence [n/N (%)] P Incidence [n/N (%)] P
Age (y) Age (y)
< 70 12/47 (26) 0.816 < 70 3/28 (11) 0.157
Z70 13/45 (29) Z70 7/24 (29)
Sex Sex
Male 14/48 (29) 0.815 Male 4/25 (16) 0.729
Female 11/44 (25) Female 6/27 (22)
ASA score ASA score
1-2 20/79 (25) 0.330 1-2 5/41 (12) 0.025
3 5/13 (38) 3 5/11 (45)
Overweight (BMIZ25) Overweight (BMIZ25)
Yes 17/80 (21) 0.003 Yes 7/45 (16) 0.120
No 8/12 (67) No 3/7 (43)
Diabetes Diabetes
Yes 5/27 (19) 0.306 Yes 3/12 (25) 0.679
No 20/65 (31) No 7/40 (18)
Heavy drinking Heavy drinker
Yes 7/14 (50) 0.051 Yes 1/4 (25) 1.000
No 18/78 (23) No 9/48 (19)
Smoking Smoking
Yes 10/30 (33) 0.454 Yes 4/11 (36) 0.190
No 15/62 (24) No 6/41 (15)
Depression Depression
Yes 5/8 (63) 0.032 Yes 3/5 (60) 0.043
No 20/84 (24) No 7/47 (15)
Diagnosis Surgery
Pancreatic cancer 13/56 (23) 0.340 HPD 4/15 (27) 0.448
Others 12/36 (33) Others 6/37 (16)
Preoperative cholangitis Preoperative cholangitis
Yes 1/21 (5) 0.069 Yes 2/8 (25) 0.642
No 9/33 (27) No 8/44 (18)
PBD PBD
Yes 10/54 (19) 0.033 Yes 4/26 (15) 0.727
No 15/38 (39) No 6/26 (23)
Bismuth classication Z3
ASA indicates American society of anesthesiologists; BMI, body mass Yes 3/21 (14) 0.722
index; PBD, preoperative biliary drainage. No 7/31 (23)
PVE
Yes 8/23 (35) 0.015
No 2/29 (7)
PBD complications are shown in Table 3. The inci-
dence of post-ERCP pancreatitis was higher in hilar biliary ASA indicates American society of anesthesiologists; BMI, body mass
obstruction (23% in hilar obstruction vs. 11% in distal index; HPD, hepatopancreatoduodenectomy; PBD, preoperative biliary
drainage; PVE, portal vein embolization.
obstruction). Cholangitis and migration/dislocation was the
major complications associated with PBD. The rate of
reinterventions for endoscopic PBD was 43% in distal
obstruction and 27% in hilar obstruction. In hilar Tables 5 and 6 showed univariate analyses of post-
obstruction, reintervention was performed in 3 patients operative complications in periampullary and hilar malig-
(16%) of ENBD group, and in 4 (57%) of EBS group nancies. Neither PBD nor preoperative cholangitis was
(P = 0.057). In distal obstruction, reinterventions rate was associated with postsurgical complications. In the explor-
similar (30% in ENBD group and 52% in EBS group, atory multivariate analyses (Table 7), overweight (body
P = 0.154). Kaplan-Meier analyses of reintervention-free mass indexZ25) and depression in periampullary malig-
period for endoscopic PBD in distal and hilar biliary nancy and PVE, American society of anesthesiologists
obstruction are shown in Figures 1 and 2. In patients with (ASA) score of 3, and depression in hilar malignancy were
hilar biliary obstruction, EBS was associated with higher associated with postsurgical complications.
cumulative incidence of need for reinterventions
(P = 0.047).
Time to Surgery and Discharge
In periampullary malignancy, the median time to
Postoperative Complications surgery and to discharge were 13 (IQR, 7 to 21) days and 50
Postoperative complications are listed in Table 4. Of (IQR, 37 to 62) days, respectively. PBD in periampullary
note, there was no inhospital mortality. A total of 25 malignancy was associated with longer time to surgery (19
patients in periampullary malignancy and 10 patients in vs. 6 d in PBD and non-PBD group, P < 0.001) and time to
hilar malignancy developed postoperative complications in discharge (56 vs. 42 d in PBD and non-PBD group,
periampullary cancer. Delayed gastric emptying is the P = 0.004). In addition, among patients undergoing PBD,
major complication (13%) in periampullary malignancy. patients with reinterventions needed longer time to surgery

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Ito et al
TABLE 7. Multivariate Analyses for Postoperative Complications
in Periampullary and Hilar Malignancy
Periampullary Malignancy Odds Ratio (95% CI)
BMIZ25 7.6 (1.9-35.6)
Depression 8.5 (1.6-51.1)
Hilar malignancy
ASA score 3 6.6 (1.1-45.6)
Depression 13.8 (1.3-203.4)
PVE 6.1 (1.1-52.0)
ASA indicates American society of anesthesiologists; BMI, body mass
index; CI, condence interval; PVE, portal vein embolization.
(28 vs. 14 d, P = 0.001) and time to discharge (61 vs. 50 d,
P = 0.009).
In hilar malignancy, the median time to surgery and
to discharge were 21 (IQR, 10 to 35) days and 53 (IQR, 35
to 76) days, respectively. PBD in hilar malignancy was
again associated with longer time to surgery (33 vs. 6 d in
PBD and non-PBD group, respectively, P < 0.001) and
time to discharge (64 vs. 45 d in PBD and non-PBD group,
respectively, P = 0.019). Reinterventions for PBD tended
to aect time to surgery (38 vs. 26 d in patients with and
without reinterventions, respectively, P = 0.080) or time
to discharge (78 vs. 56 d in patients with and without
reinterventions, respectively, P = 0.182), but not sig-
nicantly. PVE was also associated with longer time to
surgery (30 vs. 14 d, P = 0.002) and discharge (68 vs. 43 d,
P = 0.001).
DISCUSSION
Our single-center retrospective analysis showed that
PBD was associated with longer time to surgery and time to
discharge but was not a risk factor for postoperative
complications. Patient characteristics such as ASA score of
3, overweight, or depression were associated with post-
surgical complications. As previously reported,2 PBD was
associated with a signicant rate of PBD-related compli-
cations, but neither PBD nor preoperative cholangitis was
associated with postsurgical complications. Meanwhile,
PBD prolonged time to surgery and discharge. Therefore,
prevention of PBD-related complications should further be
sought to justify routine use of PBD in periampullary and
hilar malignancy.
As the role of PBD in pancreatobiliary malignancy is
to improve surgical outcomes, we evaluated the risk fac-
tors for postsurgical complications. In our study cohort,
PBD was not a risk factor for postoperative complication
in distal and hilar malignancy, including infectious com-
plications such as cholangitis or abscess. However, caution
must be paid to interpret our study results because our
cohort included patients both with and without obstruc-
tive jaundice, and PBD was performed only in patients
with jaundice. Our multivariate analysis for risk factors
for postoperative complications showed interesting
results. In addition to known risk factors for postoperative
complications,14 that is, ASA score and overweight,
depression was associated with postsurgical complication
both in periampullary and distal malignancy. The reason
for this association was unclear, but delayed gastric
emptying appeared to increase in patients with depression
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Surg Laparosc Endosc Percutan Tech  Volume 26, Number 2, April 2016
after pancreatoduodenectomy. However, this analysis was
just exploratory due to the small sample size, and the
results should be conrmed in a larger cohort.
P PVE was also associated with an increased risk of
0.004 postoperative complications, although ecacy of PVE was
0.011 previously reported.810 PVE was performed according to
the estimated volume of FRL, and the increased risk of
0.035 complications was probably related to the extended volume
0.028 of hepatectomy in patients with PVE, rather than PVE
0.038 itself.
PBD-related complications are also of importance in
pancreatobiliary surgery. Cholangitis caused by stent
clogging or migration was common in PBD and reinter-
ventions were performed in 43% and 27% in distal and
hilar biliary obstruction. This was similar to the results
shown in a randomized controlled trial by van der Gaag
et al.2 Although preoperative cholangitis did not increase
postoperative complications in our study, time to surgery or
discharge was delayed in patients with reinterventions for
PBD. When ENBD and EBS were compared, dierences
were only seen in hilar biliary obstruction: ENBD demon-
strated longer reintervention-free period. This is consistent
with a previous report15 showing ENBD was most suitable
in hilar cholangiocarcinoma, but the median time to sur-
gery in hilar malignancy with PBD was 33 days and ENBD
placement over this preoperative period poses nasal dis-
comfort to patients and impairs the quality of life. In
patients with unresectable pancreatobiliary malignancy,
self-expandable metallic stents (SEMS) showed longer stent
patency and better cost-eectiveness.16 The use of SEMS is
increasingly reported in patients undergoing neoadjuvant
chemotherapy for pancreatic cancer,17 or even resectable
pancreatic cancer.18,19 However, the role of SEMS as
PBD in resectable cancer is not fully elucidated but can
possibly prevent preoperative cholangitis. A large pro-
spective study should further be awaited to prove its safety
and ecacy.
Post-ERCP pancreatitis is also a dreadful complica-
tion in endoscopic biliary drainage, and PEP was more
frequent in hilar biliary obstruction. There appeared 2
reasons for this extremely high incidence (23%) of PEP in
hilar biliary obstruction. One is the increased risk of PEP
after transpapillary stenting in nonpancreatic cancer. The
risk of PEP is reported to be low in patients with pancreatic
head cancer,20,21 because the exocrine function is likely to
be impaired due to the pancreatic duct obstruction and
subsequent atrophic change of the distal pancreas. The
other reason is the possible compression of the pancreatic
duct orice due to medial deection of biliary drainage.22
Although severe PEP was rare in our study population, it
can be fatal and sometimes hinders surgical procedures, and
further eorts should be taken to reduce the risk of PEP in
PBD in the future.
There are some limitations to our study. First, a ret-
rospective design in a single center posed a serious bias to
our study results as discussed above. PBD was mainly
performed in patients with jaundice, and the comparison of
PBD and non-PBD groups should be interpreted in this
context. Secondly, the comparison of ENBD and EBS as
PBD was also dicult, although our results showing
superiority of ENBD in hilar biliary obstruction were
compatible with a previous study.15 As the use of ENBD
and EBS was at the discretion of endoscopists, there should
be some biases. In addition, the number of cases was too
small to draw a solid conclusion.
Surg Laparosc Endosc Percutan Tech  Volume 26, Number 2, April 2016
PBD was not associated with postoperative compli-
cations. However, reinterventions for PBD were necessary
in 43% and 27% of distal and hilar malignant biliary
obstruction and were associated with longer hospital-
ization. Therefore, improvement of PBD should be further
investigated.
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