OBJECTIVE: To investigate whether preoperative biliary drainage is beneficial for patients undergoing pancreaticoduodenectomy. METHODS: The PubMed, Cochrane Library and the Web of Science were systematically searched for relevant trials that included outcome of pancreaticoduodenectomy with and without preoperative biliary drainage from January 2010 to May 2024. The primary outcomes are postoperative pancreatic fistula and intra-abdominal infection. Data is pooled using the risk ratio or standardized mean difference with 95% confidence interval. The study protocol was registered prospectively with PROSPERO (CRD42022372584). RESULTS: A total of 39 retrospective cohort studies with 33,516 patients were included in this trial. Compared with no preoperative biliary drainage, the preoperative biliary drainage group had a longer hospital stay (SMD, 0.14). Performing preoperative biliary drainage significantly increases the risk of postoperative pancreatic fistula (RR, 1.09), intra-abdominal infection (RR, 1.09), surgical site infection (RR, 1.84), and sepsis (RR, 1.37). But preoperative biliary drainage lowers risk of bile leak (RR, 0.74). CONCLUSION: Preoperative biliary drainage before pancreaticoduodenectomy increases the risk of postoperative complications without clear overall benefits. Routine PBD is not recommended for younger patients with mild to moderate jaundice but may be considered for high-risk patients, such as those with severe infections or progressive jaundice. Optimizing preoperative biliary drainage duration and timing may help reduce complications. Further research is needed to refine patient selection and perioperative strategies.