A Meta-analysis On The Efficacy Of Preoperative Biliary Brainage For Malignant Obstructive Jaundice

Background: Malignant Obstructive jaundice is characterized by elevated serum bilirubin levels which is caused by the direct invasion or indirect compression of the bile duct by malignancies. The existing severe obstructive jaundice has been universally recognized as a potential risk factor which is associated with high peri-operative mortality and morbidity. As such, pre-operative biliary drainage has been proposed as a method of reversing the pathophysiologic disturbance seen in patients with obstructive jaundice so as to improve the prognosis. However, the results of the clinical RCTs involved are different, some are even contradictory. With the development of the EBM, Meta-analysis is just inferior to the large scale, multi-centre RCT in terms of the supply of evidence. Therefore, it is extremely necessary to perform Meta-analysis on the efficacy of the preoperative biliary drainage for patients with malignant obstructive jaundice, which will provide evidences for our clinical work.Objectives: To determine the benefits and harms of pre-operative biliary drainage for patients with malignant obstructive jaundice.Search strategy: We searched the Medline, Pubmed, the Chinese BioMedical Literature (CBM) and the CNKI (all to 2008.10) to collect all the RCTs comparing preoperative biliary drainage followed by surgery and direct surgery performed for malignant obstructive jaundice. After that, all the included RCTs undergo quality evaluation on methodology and Meta-analysis recommended by the Cochrane website.Results: Six trials with 457 patients were included, one of which specialize on the lower level obstruction group. All trials were of low methodological quality. Meta-analysis revealed that there was no significant difference in mortality (OR 0.84, 95%C1 0.46-1.53) and overall morbidity (OR 0.90, 95%CI 0.41-1.97) between the preoperative biliary drainage group and the direct surgery group for all patients with malignant obstructive jaundice. However, when all the complications directly caused by the PBD itself were excluded, PBD could significantly decrease the rate of postoperative complications (OR 0.46, 95%C1 0.30-0.72) .No significant difference was found in mortality (OR 0.40, 95%C1 0.10-1.55) and overall morbidity (OR 0.56, 95%CI 0.29-1.09) between the preoperative biliary drainage group and the direct surgery group, when it comes to the lower level bile obstruction subgroup. No appropriate trials were included for the analysis on the higher level bile obstruction subgroup except the trial conducted by Lai which undergo subgroup analysis according to the obstruction level.Authors' conclusions: Our meta-analyses illustrates that PBD could not benefit the patients with severe malignant obstructive jaundice, whether the obstruction site is lower or higher. However, the strength of evidence is low because of the poor quality of the included trials. Therefore more rigorously designed randomized clinical trials with larger sample size and advanced techniques are needed to evaluate the efficacy of PBD. However, we can concluded from this meta-analysis that high quality RCTs were extremely in short, especially those specialize on the high level obstruction.