Survival Benefit of Intraductal Radiofrequency Ablation for Malignant Biliary Obstruction: A Systematic Review with Meta-Analysis

Abstract

Background/aims: Cholangiocarcinoma (CCA) is a rare but aggressive disease with a poor survival. Recent trials have shown improved survival with intraductal radiofrequency ablation (RFA) therapy. We performed a systematic review with meta-analysis to determine the survival benefit of endoscopic RFA for unresectable extrahepatic CCA with malignant biliary obstruction (MBO).

Methods: A systematic search from 1970 to 2020 was performed in MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials. gov. We selected eligible studies reporting relative risks, hazard ratios (HRs), or odds ratios, adjusted by controlling for confounding factors of survival rate and stent patency duration, among patients with extrahepatic CCA with MBO treated with RFA with stent insertion or stent insertion only.

Results: A total of eight trials (three randomized and five nonrandomized) with a total of 420 patients were included in the metaanalysis. Pooled overall survival analysis favored RFA treatment with stent insertion (HR, 0.47; 95% confidence interval [CI], 0.34- 0.64; I2=47%; p=0.09); however, no significant difference was found in the duration of stent patency between the groups (HR, 0.79; 95% CI, 0.57-1.09; I2=7%; p=0.36).

Conclusion: RFA therapy with stent insertion may confer a survival benefit compared with stent insertion only in patients with CCA and MBO.

Keywords: Cholangiocarcinoma; Malignant biliary obstruction; Meta-analysis; Radiofrequency ablation; Survival rates.

Fig. 1.

Schematic flowchart of study enrollment, including identification, screening, eligibility, exclusion, and analysis inclusion, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines 2009. RCTs, randomized controlled trials.

Fig. 2.

Pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of overall survival rates between two groups (endobiliary radiofrequency ablation with stent vs. stent only) among patients with cholangiocarcinoma with malignant biliary obstruction (random-effect model, eight studies with 420 participants). NRS, non-randomised study; RCT, randomized controlled trial.

Fig. 3.

Pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of stent patency between two groups (endobiliary radiofrequency ablation with stent vs. stent only) among patients with cholangiocarcinoma with malignant biliary obstruction (random-effect model, four studies with 205 participants). NRS, non-randomised study; RCT, randomized controlled trial.

Fig. 4.

Funnel plot and Egger’s test for asymmetry for survival outcome analyses of eight enrolled studies. HR, hazard ratio.