In a recent multicentre randomized clinical trial, Van der Gaag et al. randomly assigned 220 patients to early surgery or preoperative biliary drainage (‘Preoperative drainage for cancer of the head of the pancreas’). The rate of serious complications was significantly higher in the preoperative drainage group (p < 0.001), mainly because of drainage-related complications. There was no difference in surgical complications or mortality. Data on costs and impact on quality of life were not presented, but it can be predicted that the preoperative drainage strategy would be more expensive and would have greater negative impact on quality of life. If forthcoming publications by this research group confirm this suggestion, the current paradigm – obstructive jaundice, endoscopic retrograde cholangiopancreatography with stenting, delayed surgery for carcinoma of the head of the pancreas – should be changed to: obstructive jaundice due to peri-ampullary carcinoma should be considered an indication for emergency surgery.

Conflict of interest: none declared. Financial support: none declared.