Changes in Preoperative Endoscopic and Percutaneous Bile Drainage in Patients with Periampullary Cancer Undergoing Pancreaticoduodenectomy in Ontario: Effect on Clinical Practice of a Randomized Trial

Background: In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (PDE) patients undergoing preoperative biliary decompression (PBD). We evaluated the effect of that publication on rates of PBD at the population level. Methods: This retrospective observational cohort study identified patients undergoing PDE for malignancy, 2005–2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing PBD within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing PDE before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of PBD. Results: Of 1997 PDE patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of PBD was 47.5% before publication, and 41.6% after (p = 0.01). The lowest PBD rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Conclusions: Rates of PBD have declined a small, but significant, amount after randomized trial publication. Persistence of PBD might relate to suboptimal knowledge translation, the role of PBD in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in PBD rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent PBD is needed.