Side-by-side placement of fully covered metal stents versus conventional 7F plastic stents in malignant hilar biliary obstruction: Prospective randomized controlled trial

Evaluating safety and efficacy of plastic versus metal stenting in malignant hilar biliary obstruction: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Stenting malignant hilar biliary obstruction (MHBO) is challenging due to its complex structure, and it is less effective than blockages in the distal bile duct area. Plastic stents (PSs) and metal stents (MSs) are commonly used for stenting MHBO. This study aims to compare the outcomes of PSs and MSs in MHBO patients.

METHODS

We conducted a search of medical databases up to March 2024. Using a fixed-effect model, we analyzed the risk ratios (RRs) of the outcomes between the PS and MS groups. We calculated the RR for clinical and technical success, reinterventions, and adverse events, as well as the hazard ratio (HR) for survival and stent patency.

RESULTS

This analysis includes five randomized controlled trials (RCTs) that met the inclusion criteria, comprising a total of 322 patients (156 in the PS group and 166 in the MS group). Significant differences (P < .05) in favor of the MS group were found in the reinterventions (RR 1.80, 95% CI 1.07-3.04), and stent patency (HR 0.54, 95% CI 0.32-0.90). There were no significant differences (P > 0.05) between the PS and MS groups regarding technical success (RR 1.01, 95% CI 0.94-1.09), clinical success (RR 0.86, 95% CI 0.69-1.07), overall survival (HR 0.71, 95% CI 0.47-1.05), stent migration (RR 0.69, 95% CI 0.08-6.02), stent occlusion (RR1.32, 95% CI 0.97-1.81), and adverse events (RR 0.80, 95% CI 0.53-1.20).

CONCLUSION

Both PS and MS are effective for managing MHBO, while MS offers greater efficacy in increased stent patency and lower reintervention rates. Key message What is already known on this topic Metal stents (MSs) and plastic stents (PSs) are used for palliative treatment of malignant hilar biliary obstruction (MHBO). MSs significantly reduced the need for reinterventions compared to PSs in patients with MHBO. What this study adds There were no significant differences between MSs and PSs in terms of technical success, clinical success, overall survival, stent migration, stent occlusion, or adverse events. How this study might affect research, practice, or policy The study's findings may prompt researchers to design more targeted studies to further investigate these specific outcomes in MHBO patients. The results encourage endoscopists to consider patient-specific factors, such as life expectancy and preference for minimizing recurrent procedures, when choosing between MSs and PSs for MHBO.

Efficacy and safety of covered self-expandable metal stents for malignant hilar biliary obstruction: systematic review and meta-analysis

BACKGROUND AND AIMS

Covered self-expandable metal stents (CSEMSs) are used for malignant hilar biliary obstruction (MHBO) management. Despite increasing evidence, a comprehensive evaluation of the efficacy and safety of CSEMSs in MHBO management is lacking.

METHODS

PubMed, EMBASE, and the Cochrane Library were screened up to March 31, 2024, for studies including MHBO treated by a CSEMS. Studies meeting predefined inclusion criteria, including adult MHBO patients treated with CSEMS placement, reporting technical success, clinical success, and adverse event rates were selected. Data synthesis and statistical analysis were performed using the random-effects model, with heterogeneity and publication bias assessment.

RESULTS

From 401 articles, 7 studies were included. Pooled technical and clinical success rates of CSEMSs were 96.7% (95% confidence interval [CI], 92.6-98.6; I2 = 0%) and 91.6% (95% CI, 86.1-95.0; I2 = 0%). Overall adverse events were reported in 16.6% of cases (95% CI, 11.2-23.9; I2 = 24%), which included cholangitis (7.4%), pancreatitis (5.9%), liver abscess (5.9%), and cholecystitis (2.8%). Stent migration and recurrent biliary obstruction (RBO) were observed in 8.9% and 49.6% of cases, respectively, with a median time to RBO of 142 days. Reintervention was successful in 92.5% of cases (95% CI, 83.1-96.9; I2 = 0%).

CONCLUSIONS

Our meta-analysis revealed high technical and clinical success rates of CSEMS placement in MHBO. Adverse events, notably cholangitis, cholecystitis, and pancreatitis, were <10%. RBO and stent migration were mitigated by CSEMS removal and successful reintervention. Our findings highlight the efficacy and safety of CSEMSs in managing MHBO, warranting further research to optimize treatment strategies.

TOKYO criteria 2024 for the assessment of clinical outcomes of endoscopic biliary drainage

The consensus-based TOKYO criteria were proposed as a standardized reporting system for endoscopic transpapillary biliary drainage. The primary objective was to address issues arising from the inconsistent reporting of stent outcomes across studies, which has complicated the comparability and interpretation of study results. However, the original TOKYO criteria were not readily applicable to recent modalities of endoscopic biliary drainage such as biliary drainage based on endoscopic ultrasound or device-assisted endoscopy. There are increasing opportunities for managing hilar biliary obstruction and benign biliary strictures through endoscopic drainage. Biliary ablation has been introduced to manage benign and malignant biliary strictures. In addition, the prolonged survival times of cancer patients have increased the importance of evaluating overall outcomes during the period requiring endoscopic biliary drainage rather than solely focusing on the patency of the initial stent. Recognizing these unmet needs, a committee has been established within the Japan Gastroenterological Endoscopy Society to revise the TOKYO criteria for current clinical practice. The revised criteria propose not only common reporting items for endoscopic biliary drainage overall, but also items specific to various conditions and interventions. The term "stent-demanding time" has been defined to encompass the entire duration of endoscopic biliary drainage, during which the overall stent-related outcomes are evaluated. The revised TOKYO criteria 2024 are expected to facilitate the design and reporting of clinical studies, providing a goal-oriented approach to the evaluation of endoscopic biliary drainage.

Updates on Endoscopic Stenting for Unresectable Malignant Hilar Biliary Obstruction

Malignant hilar biliary obstruction (MHBO) can cause obstructive jaundice and/or cholangitis necessitating appropriate biliary drainage. Endoscopic biliary stenting is the first-choice treatment, especially in unresectable cases, owing to its minimally invasive nature and utility. However, the hilar region is complex because of the branching and curving of bile ducts, making strictures in this area more complicated. Therefore, MHBO stenting is challenging, and treatment strategies have yet to be established. Furthermore, recent advances in antitumor therapies have altered the background surrounding the development of stenting strategies. Therefore, it is necessary to understand and grasp the current evidence well and to accumulate additional evidence reflecting the current situation. This study reviews the current status, issues, and prospects of endoscopic stenting for MHBO, especially in unresectable cases.