Table 1.

Absolute and relative indications for Percutaneous biliary drainage (PBD).

Indication for PDB		Comment
Absolute	Neoadjuvant therapy
	Renal dysfunction	If mild, percutaneous external drainage and fluid replacement may permit early surgery with trans-sphincteric drainage to reduce the risk of pancreatitis
	Cholangitis with organ dysfunction	If mild, percutaneous external drainage and fluid replacement may permit early surgery with trans-sphincteric drainage to reduce the risk of pancreatitis
Relative	Bilirubin level	Exact cut off leve currently unclear, see text.
	Delay to surgery	Need to consider daily rate if increase in bilirubin as this may vary from patient to patient
	Malnutrition	Ensure exocrine insufficiency corrected and balance delays to surgery, cancer progression against severity of malnutrition
	Frailty	Frail patients are less likely to tolerate complications of PBD so a difficult discussion or choice often needs to be made. For some frail patients, direct to surgery may be there best chance to have surgery as delays or complications of PBD can exacerbate frailty