An argument against routine percutaneous biopsy, ERCP, or biliary stent placement in patients with clinically resectable periampullary masses: A surgical perspective

Improved resolution of computed tomography (CT) and ultrasonography allows us to visualize the proximal extent of biliary obstruction and the presence of a periampullary mass in most patients with malignant extrahepatic biliary obstruction. Our purpose in this report is to challenge the need for preoperative percutaneous biopsy, endoscopic retrograde cholangiopancreatography, or preoperative placement of a biliary endoprosthesis in the good-risk patient in whom the imaging procedure clearly defines a periampullary mass and the proximal extent (hepatic extent) of biliary obstruction. We recently managed three patients in whom one of these invasive procedures led to a complication that delayed,prevented, or complicated appropriate operative resection of a pancreatic neoplasm. Because a negative percutaneous biopsy, cholangiographic imaging of a dilated bile/pancreatic duct clearly seen on CT or ultrasonography, or short-term preoperative biliary decompression does not alter the decision for operative exploration and may cause complications, we argue against their use in the good-risk patient with both extrahepatic biliary ob-struction and a periampullary pancreatic mass well delineated on noninvasive imaging.