Meta-Analysis
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. May 27, 2021; 13(5): 595-610
Published online May 27, 2021. doi: 10.4254/wjh.v13.i5.595
Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction — stent-in-stent or side-by-side? A systematic review and meta-analysis
Gabriel Mayo Vieira de Souza, Igor Braga Ribeiro, Mateus Pereira Funari, Diogo Turiani Hourneaux de Moura, Maria Vitória Cury Vieira Scatimburgo, João Remí de Freitas Júnior, Sergio A Sánchez-Luna, Renato Baracat, Eduardo Turiani Hourneaux de Moura, Wanderley Marques Bernardo, Eduardo Guimarães Hourneaux de Moura
Gabriel Mayo Vieira de Souza, Igor Braga Ribeiro, Mateus Pereira Funari, Diogo Turiani Hourneaux de Moura, Maria Vitória Cury Vieira Scatimburgo, João Remí de Freitas Júnior, Renato Baracat, Eduardo Turiani Hourneaux de Moura, Wanderley Marques Bernardo, Eduardo Guimarães Hourneaux de Moura, Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
Sergio A Sánchez-Luna, Division of Gastroenterology, Hepatology and Nutrition, Center for Advanced Therapeutic Endoscopy, Allegheny Health Network, Pittsburgh, PA 15212, United States
Sergio A Sánchez-Luna, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Basil I. Hirschowitz Endoscopic Center of Excellence, Birmingham, AL 35294, United States
Author contributions: de Souza GMV contributed acquisition of data, analysis, interpretation of data, drafting the article, revising the article, final approval; Ribeiro IB, Funari MP, Scatimburgo MVCV and de Freitas Júnior JR contributed analysis and interpretation of data, revising the article; de Moura DTH contributed analysis of data, interpretation of data, drafting the article, revising the article, final approval; Sánchez-Luna SA contributed interpretation of data, drafting the article, revising the article, final approval; Baracat R contributed revising the article, drafting the article, final approval; de Moura ETH contributed revising the article, drafting the article, final approval; Bernardo WM contributed analysis and interpretation of data, drafting the article, final approval; de Moura EGH contributed analysis and interpretation of data, drafting the article, revising the article, final approval.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Igor Braga Ribeiro, MD, Doctor, Research Fellow, Surgeon, Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, São Paulo 05403-010, Brazil. igorbraga1@gmail.com
Received: January 13, 2021
Peer-review started: January 13, 2021
First decision: February 24, 2021
Revised: March 11, 2021
Accepted: March 18, 2021
Article in press: March 18, 2021
Published online: May 27, 2021
ARTICLE HIGHLIGHTS
Research background

Patients with malignant hilar biliary obstruction (MHBO) benefit from bilateral palliative endoscopic drainage. However, there is no consensus on which is the optimal technique for placing a metal stent: Stent-in-stent (SIS) or side-by-side (SBS).

Research motivation

Many patients undergo palliative endoscopic retrograde cholangiopancreatography (ERCP) drainage, due to the advanced stage of the disease at the time of diagnosis, unresectable in most cases. However, choosing the best management for drainage can be a real technical challenge. Therefore, we aimed to compare both drainage techniques in an attempt to identify the optimal approach.

Research objectives

To perform a systematic review and meta-analysis of available studies that compare SIS and SBS deployment in patients with MHBO undergoing ERCP drainage.

Research methods

The systematic review and meta-analysis followed the PRISMA Guidelines. Electronic searches were performed in MEDLINE, Embase, Cochrane, LILACS, and BIREME databases, and the grey literature. Comparative cohorts and randomized controlled trials (RCTs) were included. Studied outcomes were technical and clinical success, early and late adverse events (AEs), stent patency, reintervention, and procedure-related mortality.

Research results

Four comparative cohorts and one RCT were included in the final analysis with a total of 250 patients, of whom 127 belonged to the SIS group and 123 to the SBS group. Stent patency was significantly higher in the SIS group. Procedure-related mortality was similar in both groups, and no significant differences were found in the rates of technical success, clinical success, early AEs, late AEs, and reintervention.

Research conclusions

There was no difference between the groups concerning technical and clinical success, early and late AEs, reintervention, and procedure-related mortality. However, there was longer stent patency in patients undergoing the SIS technique. This result suggests that SIS may be the preferred technique for bilateral palliative metal stent deployment in patients with inoperable MHBO.

Research perspectives

Palliative biliary drainage is an increasingly performed procedure, but without consensus on the optimal technique, SIS or SBS. There is a small number of comparative studies in the literature. Future RCTs will have an important role in elucidating the most optimal drainage technique.