Meta-Analysis
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. May 27, 2021; 13(5): 493-506
Published online May 27, 2021. doi: 10.4240/wjgs.v13.i5.493
Biliary drainage in inoperable malignant biliary distal obstruction: A systematic review and meta-analysis
Maria Vitória Cury Vieira Scatimburgo, Igor Braga Ribeiro, Diogo Turiani Hourneaux de Moura, Vitor Massaro Takamatsu Sagae, Bruno Salomão Hirsch, Mateus Bond Boghossian, Thomas R McCarty, Marcos Eduardo Lera dos Santos, Tomazo Antonio Prince Franzini, Wanderley Marques Bernardo, Eduardo Guimarães Hourneaux de Moura
Maria Vitória Cury Vieira Scatimburgo, Igor Braga Ribeiro, Diogo Turiani Hourneaux de Moura, Vitor Massaro Takamatsu Sagae, Bruno Salomão Hirsch, Mateus Bond Boghossian, Marcos Eduardo Lera dos Santos, Tomazo Antonio Prince Franzini, 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
Thomas R McCarty, Division of Gasteoenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
Author contributions: Scatimburgo MVCV, de Moura DTH, Sagae VMT, dos Santos MEL, and Franzini TAP contributed to the data acquisition; Scatimburgo MVCV, de Moura DTH, Sagae VMT, Boghossian MB, Bernardo WM, de Moura EGH, Ribeiro IB, and Hirsch BS analyzed and interpretated data; Scatimburgo MVCV, de Moura DTH, Sagae VMT, Boghossian MB, de Moura EGH, Ribeiro IB, and Hirsch BS revised the article; Scatimburgo MVCV, de Moura DTH, Sagae VMT, dos Santos MEL, Franzini TAP, Bernardo WM, and de Moura EGH drafted the article; Scatimburgo MVCV, de Moura DTH, Franzini TAP, Bernardo WM, and de Moura EGH contributed to final approval; McCarty TR reviewed the English.
Conflict-of-interest statement: The authors do not have any conflicts of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist statement, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist statement.
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 24, 2021
Peer-review started: January 24, 2021
First decision: March 29, 2021
Revised: March 30, 2021
Accepted: April 23, 2021
Article in press: April 23, 2021
Published online: May 27, 2021
Processing time: 116 Days and 10 Hours
Abstract
BACKGROUND

Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction (MDBO).

AIM

To compare the safety and efficacy of plastic stent (PS) vs self-expanding metal stent (SEMS) placement for treatment of MDBO.

METHODS

This meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A comprehensive search was performed in MEDLINE, Cochrane, Embase, Latin American and Caribbean Health Sciences Literature, and grey literature to identify randomized clinical trials (RCTs) comparing clinical success, adverse events, stent dysfunction rate, reintervention rate, duration of stent patency, and mean survival. Risk difference (RD) and mean difference (MD) were calculated and heterogeneity was assessed with I2 statistic. Subgroup analyses were performed by SEMS type.

RESULTS

Twelve RCTs were included in this study, totaling 1005 patients. There was no difference in clinical success (RD = -0.03, 95% confidence interval [CI]: -0.01, 0.07; I2 = 0%), rate of adverse events (RD = -0.03, 95%CI: -0.10, 0.03; I2 = 57%), and mean patient survival (MD = -0.63, 95%CI: -18.07, 19.33; I2 = 54%) between SEMS vs PS placement. However, SEMS placement was associated with a lower rate of reintervention (RD = -0.34, 95%CI: -0.46, -0.22; I2 = 57%) and longer duration of stent patency (MD = 125.77 d, 95%CI: 77.5, 174.01). Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS (RD = 152.25, 95%CI: 37.42, 267.07; I2 = 98% and RD = 101.5, 95%CI: 38.91, 164.09; I2 = 98%; respectively). Stent dysfunction was higher in the covered SEMS group (RD = -0.21, 95%CI: -0.32, -0.1; I² = 205%), with no difference in the uncovered SEMS group (RD = -0.08, 95%CI: -0.56, 0.39; I² = 87%).

CONCLUSION

While both stent types possessed a similar clinical success rate, complication rate, and patient-associated mean survival for treatment of MDBO, SEMS were associated with a longer duration of stent patency compared to PS.

Keywords: Biliary tract neoplasms; Stents; Protheses; Malignancy; Biliary system; Cancer

Core Tip: Bile duct or pancreatic malignancies that result in malignant distal biliary obstruction (MDBO) are often associated with a poor prognosis. Currently, palliative treatment via endoscopic biliary drainage is considered the treatment of choice for unresectable or inoperable MDBO. In this systematic review and meta-analysis of randomized controlled trials, we compared the efficacy and safety of plastic stent (PS) vs self-expanding metal stent (SEMS) placement. We concluded that SEMS placement had a longer duration of patency, lower rate of reintervention, and lower rate of stent dysfunction compared to PS in patients with MDBO. There was no difference in outcomes of clinical success, mean patient survival, and overall adverse events.