Pre-operative percutaneous transhepatic biliary drainage: The results of a controlled trial

The operative mortality for biliary tract obstruction due to malignancy is high. In 1981 a controlled clinical trial of pre‐operative percutaneous drainage was started at the Royal Postgraduate Medical School. At the time of percutaneous transhepatic cholangiography patients were randomized either to laparotomy or to pre‐operative percutaneous transhepatic biliary drainage (PTBD) followed by laparotomy. Only patients with malignant biliary tract obstruction and serum bilirubin greater than 100 μmol/l were included. Seventy patients entered the trial, and five were withdrawn. Of the 65 remaining, 31 underwent laparotomy and 34 had pre‐operative PTBD followed by laparotomy. The median duration of drainage was 18 days and during this time the median bilirubin fell from 305 to 115 m̈mol/l. Five patients required early surgery for complications of PTBD and two died within 30 days of surgery. The mortality for laparotomy was 19 per cent (6/31) compared with 32 per cent (11/34) for drainage plus laparotomy. This trial highlights the hazards of PTBD in high risk patients and has failed to demonstrate a reduction in mortality with the use of pre‐operative PTBD.