# Biliary Drainage During Neoadjuvant Chemotherapy in Pancreatic Cancer: Evidence and Practical Recommendations

## TL;DR

The paper reviews strategies for biliary drainage in pancreatic cancer patients undergoing chemotherapy to prevent complications and ensure treatment continuity.

## Contribution

The paper provides evidence-based practical recommendations for biliary drainage during neoadjuvant chemotherapy in pancreatic cancer.

## Key findings

- ERCP with self-expandable metal stents offers longer patency and fewer reinterventions compared to plastic stents.
- Endoscopic ultrasound-guided drainage is a valuable option after failed ERCP or in selected patients.
- Percutaneous drainage is recommended for specific clinical scenarios.

## Abstract

Pancreatic cancer often causes jaundice by blocking the bile duct, which can delay neoadjuvant chemotherapy. Preoperative biliary drainage is therefore used to normalize bilirubin, prevent cholangitis, and avoid unplanned hospitalizations. This review summarizes evidence and practical recommendations for drainage during chemotherapy in resectable and borderline resectable disease. ERCP is typically first line. Compared with plastic stents, self-expandable metal stents usually provide longer patency and fewer reinterventions across the planned treatment course. EUS-guided drainage is an important option after failed ERCP and may be primary in selected patients, while percutaneous drainage is reserved for specific situations.

Pancreatic cancer frequently presents with obstructive jaundice resulting from distal malignant biliary obstruction. Neoadjuvant chemotherapy (NAC) is increasingly applied in resectable and borderline resectable disease. In this context, uncontrolled cholestasis or cholangitis may hinder timely chemotherapy initiation and cause unplanned hospitalizations and treatment delays; therefore, preoperative biliary drainage is essential to ensure safe and uninterrupted NAC. This review summarizes current biliary drainage strategies during NAC, focusing on key clinical goals, maintaining durable patency throughout the planned NAC course, minimizing infectious and procedure-related morbidity, reducing the need for reintervention, and avoiding adverse effects on subsequent pancreatoduodenectomy, as well as on practical decision-making in clinical practice. We compare transpapillary drainage via endoscopic retrograde cholangiopancreatography (ERCP) using plastic stents and self-expandable metal stents (SEMSs) and discuss the emerging “slim” fully covered SEMSs designed to reduce the risks of pancreatitis and cholecystitis while maintaining sufficient patency. Endoscopic ultrasound-guided biliary drainage is also reviewed as an important salvage option after failed ERCP and as a potential primary approach in selected patients, and we also discuss conventional percutaneous approaches. Overall, current evidence supports an individualized, algorithm-based strategy that prioritizes durable internal drainage to maintain NAC schedules, reserves percutaneous transhepatic biliary drainage for specific indications, and underscores the need for further prospective studies evaluating long-term surgical and oncologic outcomes in resectable disease.