Abstract
Pancreaticoduodenectomy (PD) is the standard procedure for periampullary and pancreatic head malignancies, often performed in the context of obstructive jaundice. Preoperative biliary drainage (PBD) is used to alleviate jaundice, but its impact on postoperative outcomes remains controversial due to conflicting evidence regarding its risks and benefits. This systematic review aims to synthesize the most recent evidence on the impact of PBD on postoperative outcomes following PD. A systematic literature search was conducted across five electronic databases (PubMed, Scopus, Web of Science, Embase, CINAHL) for studies published between 2020 and 2025. Twelve studies, comprising retrospective cohort analyses, were included after a rigorous screening process. Data on study characteristics, patient populations, and postoperative outcomes were extracted. The risk of bias was assessed using the ROBINS-I tool, and a qualitative synthesis was performed due to the heterogeneity of the included studies. The evidence indicates a dualistic impact of PBD. It is consistently associated with a higher risk of infectious complications, including surgical site and intra-abdominal infections. However, the preoperative bilirubin level is a critical effect modifier; in patients with severe hyperbilirubinemia, PBD appears to mitigate the high risks of overall morbidity and mortality associated with profound jaundice. The effect of PBD on specific complications like postoperative pancreatic fistula and delayed gastric emptying was ambiguous. The timing of PBD also influences outcomes, with shorter intervals potentially reducing infectious risks. The overall methodological quality of the included studies was predominantly low to moderate risk of bias. The decision to implement PBD should not be universal but individualized. While PBD introduces a significant risk of infectious morbidity, it may be a crucial risk-mitigation strategy in severely jaundiced patients. The procedure's benefits are likely contingent on specific bilirubin thresholds and careful consideration of drainage timing. Future research should focus on validating these thresholds and optimizing perioperative protocols.