BACKGROUND: Preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) continues to be routine in many centers despite retrospective and randomized data showing that PBD increases perioperative infectious complications. METHODS: Review of a prospectively maintained database identified 340 consecutive patients with pancreatic adenocarcinoma who underwent PD between 2000 and 2005. From this cohort, 94 PBD and 94 nonstented (no-PBD) patients were matched for age, gender, preoperative albumin, and bilirubin levels (PBD group: prestent bilirubin; no-PBD group: preoperative bilirubin). RESULTS: The majority of PBD patients (89%) underwent internal endoscopic biliary drainage. Stent-related complications occurred in 46 patients (23%) and resulted in a significant delay in time to resection. In the matched-pair comparison, there was more operative blood loss in PBD patients, but similar operative times, transfusions, and hospital stay. Bile cultures were positive in 82% of PBD patients versus 7% no PBD. There was a statistically significant increase in infectious complications including wound infections and intra-abdominal abscess in PBD patients, but equal incidence of anastomotic leak. CONCLUSIONS: In this case-matched control study, PBD was associated with a stent-related complication rate of 23% and resulted in a twofold increase in postpancreatectomy infectious complications. The routine use of PBD remains unjustified.