Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results

Abstract

Background: Surgical bypass and endoscopic stents are available for palliative bypass of malignant distal biliary obstruction.

Aim: Comparison of reported outcomes in randomized controlled trials (RCTs) which included surgery, endoscopic plastic stents or endoscopic metal stents in palliative relief of malignant distal biliary obstruction.

Methods: Systematic review and meta-analysis of published literature and conference proceedings review to June 2006.

Results: We found 24 studies, containing 2436 patients, which met our inclusion criteria. Endoscopic stenting with plastic stents (three studies) is associated with a lower risk of complications (RR 0.60, 95% CI 0.45-0.81), but a higher risk of recurrent biliary obstruction (RR 18.59, 95% CI 5.33 -64.86) than traditional surgical bypass. Self-expanding metal stents (seven studies) are associated with a significantly reduced risk of recurrent biliary obstruction at 4 months (RR 0.44, 95% CI 0.3, 0.63), or prior to death or end of study (RR 0.52, 95% CI 0.39-0.69), but are not superior to plastic stents in terms of technical success, therapeutic success, mortality or complications. Cost-effectiveness outcomes were not suitable for meta-analysis. No other plastic stent designs have been demonstrated to be superior to polyethylene stents (12 studies).

Conclusions: Endoscopic metal stents are the intervention of choice in patients with malignant distal biliary obstruction, producing similar outcomes to plastic stents, but with improved patency rates.