Preoperative biliary decompression preceding pancreaticoduodenectomy with plastic or self-expandable metallic stent

Impact of biliary drainage prior to pancreatectomy

BACKGROUND

There is still a lack of clarity about the benefits of preoperative biliary drainage (PBD), which was introduced to improve the perioperative outcome in patients with obstructive jaundice caused by a periampullary tumour. The aim of this study was to determine whether operative and postoperative complications increase in patients undergoing PBD during pancreatoduodenectomy (PD).

MATERIAL AND METHODS

Retrospective examination was made of patients who underwent PBD for a periampullary tumour in our hospital between 2006 and 2014. From these, the patients were identified who had PBD with endoscopic retrograde cholangiopancreatography and these patients were further separated into two groups, as one group of patients with plastic stents and the other group of patients with metallic stents. Patients with pancreas head cancer were also separated into two groups as those who were and were not applied with PBD. The preoperative, intraoperative and postoperative characteristics of the patients were evaluated.

RESULTS

A total of 123 patients were retrospectively reviewed. Biliary stent placement with PBD was applied to 48 patients, of whom 31 had metallic stents and 17 had plastic stents. In general, there was no difference between the PBD and the non-PBD groups in respect of the preoperative, operative and postoperative results. When patients with tumour of the pancreas head only were examined, the rate of wound infection was higher in the PBD group and there was no difference in the other parameters. Moreover, there was no difference between the patients with metallic stents and those with plastic stents in respect of outcomes.

CONCLUSIONS

With the exception of wound site infection, although no difference was observed between the PBD and the non-PBD groups based on intraoperative and postoperative complications, because of the distinctive inherent complications of PBD it is essential to manage such patients properly and to carefully select the patients for the PBD procedure.

Covered self-expandable metallic stent versus plastic stent for preoperative endoscopic biliary drainage in patients with pancreatic cancer: a multi-center retrospective cohort study

BACKGROUND

Expanding indications for neoadjuvant chemotherapy (NAC) for resectable pancreatic cancer prolong the period from diagnosis to surgery. In resectable pancreatic cancer with malignant biliary obstruction (MBO), the biliary drainage method without any biliary events is ideally required to safely perform NAC as planned. Plastic stents (PS) have been traditionally used for preoperative biliary drainage; however, recently, covered self-expandable metallic stents (CSEMS) have emerged as a tool for preoperative biliary drainage.

AIMS

To compare CSEMS with PS for preoperative biliary drainage in the management of resectable pancreatic cancer with MBO.

METHODS

In this multicenter retrospective cohort study, we compared CSEMS with PS for preoperative biliary drainage in patients with pancreatic cancer at three tertiary care centers between 2008 and 2019.

RESULTS

Of the 120 enrolled patients, 45 underwent CSEMS and 75 underwent PS. No significant difference was observed in the basic characteristics between the groups. The rate of recurrent biliary obstruction (RBO) was significantly lower and the time to RBO was significantly longer in the CSEMS group. In multivariate analysis, CSEMS was an independent factor for a longer RBO. However, pancreatitis and cholecystitis were more common in the CSEMS group. The surgery-related adverse events were not significantly different between the two groups, except for longer surgery time and time to discharge in the CSEMS group.

CONCLUSIONS

CSEMS for preoperative endoscopic biliary drainage in patients with pancreatic cancer reduced RBO, although the risk for pancreatitis or cholecystitis could be increased.

Efficacy of 6‐mm diameter fully covered self‐expandable metallic stents in preoperative biliary drainage for pancreatic ductal adenocarcinoma

Objectives

Methods

Results

Conclusion

Superiority of Self-Expandable Metallic Stents Over Plastic Stents in Treatment of Malignant Distal Biliary Strictures

BACKGROUND & AIMS

Treatment of malignant biliary strictures with endoscopic retrograde cholangiopancreatography (ERCP) guided stent placement is highly effective. Our objective was to compare the efficacy and adverse outcomes between plastic stents (PS) and self-expandable metallic stents (SEMS).

METHODS

A cohort study was performed of all consecutive patients who underwent ERCP with stent placement for the management of malignant biliary stricture. Comparisons on clinical success, patency duration, stent dysfunction, unplanned reintervention and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with clinical success, need for reintervention, and stent dysfunction.

RESULTS

From 2012 to 2019, 1139 patients underwent ERCP with PS placement while 1008 patients received SEMS for the management of malignant biliary stricture. In distal strictures, SEMS reported a significantly higher rate of clinical success compared with PS (94.1% vs 87.4%, P < 0.001) and a lower rate of unplanned reintervention (17.1% vs 27.4%, P < 0.001). In hilar strictures, the rates of clinical success and unplanned intervention were comparable. The patency duration and time to unplanned reintervention were significantly longer with SEMS than PS, irrespective of stricture location. In distal stricture, PS was associated with a significantly higher rate of cholangitis than SEMS (6.9% vs 2.4%; P < .001) but a lower rate of pancreatitis (3.6% vs 6%; P = 0.021).

CONCLUSION

Given superior efficacy, durability and lower rates of cholangitis, SEMS should be offered as the first line endoscopic treatment option for malignant distal biliary stricture. For malignant hilar stricture, SEMS is an attractive alternative to PS in some cases by offering a comparable efficacy with a superior durability.

Intraoperative Bile Culture in Pancreaticoduodenectomy: Teaching Old Dogma New Tricks

INTRODUCTION

Biliary stents increase surgical site infections (SSIs) following pancreaticoduodenectomy due to bactibilia and contaminated intraoperative bile spillage. Intraoperative bile culture (IOBC) is performed to guide empiric therapy for SSIs; however, its utility is poorly studied. We sought to evaluate IOBC and the interplay between stenting, bactibilia, and SSI following pancreaticoduodenectomy.

METHODS

Patients undergoing pancreaticoduodenectomy from January 2008 to April 2020 were identified through our institutional National Surgical Quality Improvement Project (NSQIP) database; patients without IOBC were excluded. Odds of SSI were analyzed with multivariable logistic regression.

RESULTS

Four-hundred-eighty-three patients were identified. One-hundred-eighty-nine (39%) patients had plastic stents and 154 (32%) had metal stents. Three-hundred-twenty-nine (96%) patients with stents had bactibilia versus 18 (13%) without stents (P < 0.001). The biliary microbiome and antibiotic resistance patterns in patients with metal and plastic stents were nearly identical. Of 159 NSQIP-defined SSIs, most were incisional (n = 92, 58%). Bactibilia and stent presence were associated with incisional (OR 3.69 and 3.39, both P < 0.001) but not organ space SSI (P > 0.1); however, stent type was not (P > 0.5). Of the 73 speciated SSI cultures, an IOBC-identified organism was present in 42 (58%), while at least one organism not found in the IOBC was present in 49 (67%).

CONCLUSION

Bactibilia is associated with incisional but not organ space SSI following pancreaticoduodenectomy and is strongly associated with stent presence. Stent type does not independently influence the biliary microbiome or SSI risk. IOBC has a poor ability to predict causative organisms in SSIs following pancreaticoduodenectomy and is not recommended for routine use.

Covered self-expandable metal stents versus plastic stents for preoperative biliary drainage in patient receiving neo-adjuvant chemotherapy for borderline resectable pancreatic cancer: Prospective randomized study

OBJECTIVES

This single-center comparative randomized superiority study compared biliary stenting using fully covered self-expandable metal stents (FCSEMS) and biliary stenting using plastic stents (PS) in preoperative biliary drainage of patients with borderline resectable pancreatic cancer (BRPC) who are planned to undergo a single regimen of neo-adjuvant chemotherapy (NAC).

METHODS

Twenty-two patients with BRPC who required preoperative biliary drainage before NAC (Gemcitabine plus Nab-paclitaxel) were randomly assigned 1:1 to the FCSEMS or PS group. The primary endpoint was the rate of stent dysfunction until surgery or tumor progression. Secondary endpoints were stent patency, number of re-interventions, adverse events of endoscopic retrograde biliary drainage (EBD), operation time, volume of intraoperative bleeding, postoperative hospitalization, postoperative adverse events and medical costs.

RESULTS

Eleven patients in each of the groups reached the primary endpoint. The FCSEMS group showed a significantly lower rate of stent dysfunction (18.2% vs. 72.8%, P = 0.015), longer stent patency (P = 0.02), and lower number of re-interventions for stent dysfunction (0.27 ± 0.65 vs. 1.27 ± 1.1, P = 0.001) than the PS group. The adverse events of EBD, operation time, volume of intraoperative bleeding, postoperative hospitalization, postoperative adverse events and medical costs did not significantly differ between the two groups.

CONCLUSIONS

In patients with BRPC for preoperative biliary drainage, stent dysfunction occurred less frequently with FCSEMSs than with PSs. In addition, FCSEMS and PS provided similar preoperative management of BRPC in terms of the safety of surgery and medical costs. (UMIN ID000030473).

Comparison of metal stents versus plastic stents for preoperative biliary drainage: a meta-analysis of five randomized controlled trials

BACKGROUND

Although routine preoperative biliary drainage (PBD) is generally not recommended for patients with malignant distal biliary obstruction (MDBO), it is still necessary in many cases. The objective of this study is to compare the effects of metal stents (MSs) and plastic stents (PSs) on PBD in patients with MDBO.

METHODS

All the randomized controlled trials (RCTs) that compared MS with PS for PBD and published from the date of database establishment to September 2020 were identified by searching the PubMed, EMBASE and Cochrane databases.

RESULTS

Five RCTs involving 445 patients were included. There were 201 cases in the MS group, with 244 in the PS group. Re-interventions (relative risk (RR) = 0.40, 95% confidence interval (CI) 0.21-0.75, P = 0.004), stent occlusions (RR = 0.36, 95% CI 0.18-0.75, P = 0.006), postoperative complications (RR = 0.76, 95% CI 0.59-0.97, P = 0.03) and preoperative cholangitis (RR = 0.19, 95% CI 0.05-0.78, P = 0.02) were lower in the MS group than in the PS group. Preoperative pancreatitis (RR = 2.11, 95% CI 1.06-4.19, P = 0.03) was higher in the MS group than in the PS group. No significant difference was observed in the overall preoperative complications, postoperative pancreatic fistulas, delayed gastric emptying, wound infections and postoperative bleeding between these two groups.

CONCLUSIONS

MS and PS exerted a similar effect on PBD, but PS had a higher risk of preoperative stent obstruction and postoperative complications, requiring more frequent interventions preoperatively. However, larger sample and higher quality RCTs are necessary for further verification.

Use of self-expandable metallic stents for endoscopic biliary decompression decreases stent complications in pancreatic cancer patients receiving chemotherapy

Background

Both plastic stents and self-expandable metallic stents (SEMSes) are used for endoscopic biliary decompression (BD) among patients with pancreatic cancer (PAC). Cholangitis or stent occlusion often interrupts or ends chemotherapy. We investigated cholangitis, stent occlusion, and chemotherapy interruption rates for SEMSes and plastic stents among patients receiving chemotherapy for PAC.

Materials and methods

We retrospectively analyzed data for 293 PAC patients who received a biliary stent at Helsinki University Hospital during 2000–2017. Patients received chemotherapy as palliative treatment (PT: n = 187) or neoadjuvant treatment (NAT: n = 106). Among participants, 229 had a plastic stent (PT: n = 138, NAT: n = 91) and 64 had a SEMS (PT: n = 49, NAT: n = 15).

Results

Overall, 15.6% (n = 10) of patients with SEMSes (PT: 20.4%, n = 10, NAT: 0%) and 53.0% (n = 121) of patients with plastic stents (PT: 69.3%, n = 95, NAT: 28.5%, n = 26) experienced one or more stent complications (p < 0.001). Cholangitis developed in 6.3% (n = 8) of PT patients with SEMSes. No patients with SEMSes receiving NAT (n = 15) experienced cholangitis. However, 31.9% (PT: 42.8%, n = 59, p = 0.001; NAT: 15.4%, n = 14, p = 0.211) of patients with plastic stents developed cholangitis. Among all patients receiving NAT or PT, cholangitis interrupted chemotherapy 6 times (9.4%) in SEMS patients and 61 times (26.6%) in plastic stent patients (p = 0.004). Stent occlusion without cholangitis interrupted NAT or PT 2 times (2.1%) in SEMS patients and 31 times (13.5%) in plastic stent patients (p = 0.023).

Conclusions

SEMS is recommended for BD among patients with PAC receiving chemotherapy. Among both PT and NAT patients, patients with SEMS experience a lower stent failure rate, lower rate of cholangitis, and fewer chemotherapy interruptions than patients with plastic stents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08327-y.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Comparison of double-layer large-diameter and conventional small-diameter plastic stents for preoperative biliary drainage in resectable distal malignant biliary obstruction

The use of a plastic stent (PS) in resectable patients with distal malignant biliary obstruction (DMBO) is uncommon due to the high failure rate of this method. This study evaluated the efficacy and safety of a double-layer, large-diameter PS as a bridge to surgery compared with a conventional PS. This was a single-center retrospective cohort study. In total, 129 consecutive patients with DMBO underwent pancreaticoduodenectomy between January 2011 and March 2018. Fifty-five patients who preoperatively underwent plastic biliary drainage were enrolled. The patients were divided into two groups based on stent diameter: a large-diameter plastic stent (LPS) group and a small-diameter plastic stent (SPS) group. The primary endpoint was the stent patency period, and the secondary endpoint was the medical cost. Thirty-six patients received SPSs; 19 patients received LPSs. The patency rate until surgery was significantly higher in the LPS group than in the SPS group (89.5% vs. 41.7%, P = 0.0006). Multivariate analysis revealed that LPS use was significantly associated with sufficient stent patency. The total cost of LPS use was significantly lower than that of SPS use. LPSs had longer patency and reduced medical costs than SPSs. LPSs may be suitable for patients with DMBO who are scheduled to undergo surgery.

Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

Background

Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD).

Objectives

To determine whether PBD is associated with more complications after PD.

Methods

Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate.

Results

There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without.

Conclusions

PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis

BACKGROUND

Controversy remains about the best pre-operative management of jaundice in patients with resectable pancreatic head cancer (RPC) undergoing planned pancreaticoduodenectomy (PD).

OBJECTIVE

The aim of this study was to compare rates of post-operative complications in patients undergoing four pre-operative approaches (POA): preoperative biliary drainage with plastic stent (PBD-PS), metal stent (PBD-MS), and percutaneous transhepatic drain (PBD-PT), or no pre-operative biliary drainage (NPBD).

METHOD

A study was included in the systematic review if it assessed the effects of PBD on post-operative outcomes in jaundiced patients with RPC. Endpoints were the rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. A network meta-analysis (NMA) was performed to rank the POAs from the best to worst, for each outcome.

RESULTS

Thirty-two studies were included in the systematic review. Ten out of 32 studies included in the systematic review reported at least one of the 4 outcomes of interest and thus were used for NMA. The calculated odds ratios and P-scores ranked NPBD as the best approach. There was insufficient evidence to determine the best modality of PBD among PBD-PS, PBD-MS and PBD-PT.

CONCLUSIONS

No preoperative biliary drainage may be the best management of preoperative jaundice in patients with RPC before PD. Further studies are needed to determine the best modality in patients that need PBD.

Preoperative biliary drainage using a fully covered self-expandable metallic stent for pancreatic head cancer: A prospective feasibility study

Background/Aims

The role of endoscopic preoperative biliary drainage (PBD) for pancreatic head cancer is controversial because of the high incidence of stent occlusion before surgery. This study was performed to evaluate the feasibility and safety of PBD using a fully covered self-expandable metallic stent (FCSEMS).

Patients and Methods

This multicenter prospective study involved 26 patients treated for pancreatic head cancer with distal bile duct obstruction from April 2011 to March 2013. An FCSEMS was endoscopically placed in 24 patients. Among these, 7 patients were diagnosed with unresectable cancer, and 17 underwent surgery at a median of 18 days after FCSEMS placement. The main outcome measure was preoperative and postoperative adverse events.

Results

Two adverse events (cholecystitis and insufficient resolution of jaundice) occurred between FCSEMS placement and surgery (12%). Postoperative adverse events occurred in eight patients (47%). The cumulative incidence of stent-related adverse events 4 and 8 weeks after FCSEMS placement among the 24 patients who underwent this procedure were 19%.

Conclusions

PBD using an FCSEMS is feasible in patients with resectable pancreatic head cancer. Placement of an FCSEMS can be an alternative PBD technique when surgery without delay is impossible. A larger randomized controlled trial is warranted.

Preoperative Stenting for Benign and Malignant Periampullary Diseases: Unnecessary if Not Harmful

Preoperative biliary drainage (PBD) is often performed in patients with jaundice with the presumption that it will decrease the risk of postoperative complications. PBD carries its own risk of complications and, therefore, has been controversial. Multiple randomized controlled trials and metaanalyses have shown that PBD has significantly increased overall complications compared with surgery alone. As such, the routine application of PBD should be avoided except in a subset of clinical situations. This is discussed in detail in this article.

Influence of cholangitis after preoperative endoscopic biliary drainage on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures

BACKGROUND AND AIM

Preoperative cholangitis after preoperative drainage has been reported to increase postoperative complications, particularly pancreatic fistula. We therefore examined the effects of cholangitis after preoperative endoscopic biliary drainage (EBD) on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures.

METHODS

The study group comprised 102 patients who underwent EBD among patients who underwent surgery.

RESULTS

Of the 102 patients, 33 (32%) had postoperative pancreatic fistulas, and 56 (55%) had preoperative cholangitis after preoperative drainage. Analysis of risk factors for preoperative cholangitis showed that a total bilirubin level of 2.9 mg/dL or higher (hazard ratio [HR], 2.95; 95% confidence interval [CI], 1.223-7.130; P = 0.016) and a surgical waiting time of 29 days or longer (HR, 4.23; 95% CI, 1.681-10.637; P = 0.02) were independent risk factors for cholangitis. Patients with preoperative cholangitis had a significantly higher incidence of pancreatic fistula than did patients without preoperative cholangitis (78.8 vs 21.2%; P = 0.001). Patients with biliary cancer had a significantly higher incidence of pancreatic fistula than did those with pancreatic cancer (72.7 vs 27.2%; P = 0.005). Multivariate analysis showed that preoperative cholangitis (HR, 4.8; 95% CI, 1.785-12.992; P = 0.001) and biliary cancer (HR, 3.5; 95% CI, 1.335-8.942; P = 0.006) were significant independent risk factors for postoperative pancreatic fistula.

CONCLUSION

Prevention of preoperative cholangitis, a risk factor for postoperative pancreatic fistula, is likely to decrease the incidence of postoperative pancreatic fistula.

Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy: review of current status

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.

Outcomes of preoperative biliary drainage from a single tertiary center: Is there still a role for plastic stents?

OBJECTIVES

Preoperative biliary drainage (PBD) can relieve symptoms of cholestasis, but carries risk of procedural complications. Metal stents have wider lumens and longer patency, although plastic stents (PS) remain in use. We reviewed the outcomes after PBD in patients with cholestasis.

METHODS

Patients with symptomatic cholestasis who were likely to wait for over 2 weeks before surgery and were thus treated with PBD between January 2011 and May 2015 were included. Patients were evaluated for stenting-related complications, time interval to surgery, resection rate, improvement in bilirubin level and surgical complications.

RESULTS

Forty patients underwent PBD by endoscopic retrograde cholangiopancreatography (ERCP). Of these, 36 patients received the placement of PS, one received a metal stent and the remaining three required percutaneous drainage due to unsuccessful biliary cannulation. Serum bilirubin declined from 172 μmol/L (baseline) to 14 μmol/L at 30 days (P < 0.0001). Median time interval from ERCP to surgery in all patients was 5 weeks (range 2-36 weeks). Preoperative stenting-related complications occurred in seven patients after a median of 3 weeks (range 1-6 weeks). Median time to surgery was similar in patients with and without stenting-related complications (5 weeks vs 4 weeks, respectively, P = 0.33). Surgery was completed in 32 (80%) patients, with a post-Whipple complication rate of 53%.

CONCLUSIONS

PBD using mostly PS was effective in reducing bilirubin levels and did not detrimentally affect time interval to surgery. Median time interval to stenting-related complication occurred after 3 weeks, suggesting PS may be most useful for short-term PBD.

Systematic review and meta-analysis of metal versus plastic stents for preoperative biliary drainage in resectable periampullary or pancreatic head tumors

BACKGROUND

Preoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents when considering stent-related complications. Aim of the present systematic review and meta-analysis is to compare the rate of endoscopic re-intervention before surgery and postoperative outcomes of metal versus plastic stents in patients with resectable periampullary or pancreatic head neoplasms.

METHODS

We conducted a bibliographic research using the National Library of Medicine's PubMed database, including both randomized controlled trials (RCTs) and non-RCTs. Quantitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Statistical heterogeneity was assessed using the I(2) tests.

RESULTS

One RCT and four non-RCTs were selected, including 704 patients. Of these, 202 patients (29.5%) were treated with metal stents and 502 (70.5%) with plastic stents. The majority of patients (86.4%) had pancreatic cancer. The rate of endoscopic re-intervention after preoperative biliary drainage was significantly lower in the metal stent (3.4%) than in the plastic stent (14.8%) group (p < 0.0001). The rate of postoperative pancreatic fistula was significantly lower in the meta stent group as well (5.1% versus 11.8%, p = 0.04). The rate of post-operative surgical complications and of - post-operative mortality did not differ between the two groups.

CONCLUSIONS

Although the present systematic review and meta-analysis demonstrates that metal stent are more effective than plastic stents for PBD in patients with resectable periampullary tumors, randomized controlled trials are needed in order to confirm these data with a higher level of evidence.

Malignant Biliary Obstruction: Evidence for Best Practice

What should be done next? Is the stricture benign? Is it resectable? Should I place a stent? Which one? These are some of the questions one ponders when dealing with biliary strictures. In resectable cases, ongoing questions remain as to whether the biliary tree should be drained prior to surgery. In palliative cases, the relief of obstruction remains the main goal. Options for palliative therapy include surgical bypass, percutaneous drainage, and stenting or endoscopic stenting (transpapillary or via an endoscopic ultrasound approach). This review gathers scientific foundations behind these interventions. For operable cases, preoperative biliary drainage should not be performed unless there is evidence of cholangitis, there is delay in surgical intervention, or intense jaundice is present. For inoperable cases, transpapillary stenting after sphincterotomy is preferable over percutaneous drainage. The use of plastic stents (PS) has no benefit over Self-Expandable Metallic Stents (SEMS). In case transpapillary drainage is not possible, Endoscopic Ultrasonography- (EUS-) guided drainage is still an option over percutaneous means. There is no significant difference between the types of SEMS and its indication should be individualized.

Choosing the appropriate strategy in managing malignant biliary obstruction

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.

Endoscopic treatment of malignant biliary strictures

Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.