Preoperative biliary drainage (PBD) using self-expanding metal stents (SEMS) is noninferior to early surgery for pancreatic cancer patients, impacting surgical timing decisions.

• Serious adverse events were similar: 29.0% in PBD vs. 26.5% in early surgery (p = 0.011 for noninferiority).
• 82.6% of PBD patients had curative surgery versus 88.5% in the early surgery group.

Surgeons can consider PBD with SEMS to manage delays without increasing risk.

• Mortality rates were comparable: 7.9% in PBD and 8.0% in early surgery during follow-up.