MANAGEMENT OF STENT REOBSTRUCTION IN PATIENTS WITH DISTAL MALIGNANT BILIARY OBSTRUCTION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Aims Covered or uncovered self-expandable metallic stents (SEMS) placed in patients with malignant biliary obstruction (MBO) can occlude in 19-40%, but optimal management is unclear. However data suggest that the higher cost of an initial SEMS may be mitigated by the reduced need for repeated ERCP . We summarize the current evidence regarding management of occluded SEMS in patients with malignant biliary obstruction

Methods We searched Pubmed, Embase, and Web of Science using pre-defined criteria, and reviewed bibliographies of included studies. Data were independently abstracted by two investigators, and analyzed using RevMan. We compared strategies of second SEMS versus plastic stents with respect to the following outcomes: rate of stent re-occlusion, duration of second stent patency, and survival. Pooled analysis wasperformedusing a Review manager (Cochrane) software.

Results Ten retrospective were included. Management options were placement of an uncovered SEMS (n=125), covered SEMS (n=106), plastic stent (n=135), percutaneous biliary drain (n=7). Relative risk of re-occlusion was not significantly different in patients with second SEMS compared to plastic stents (RR 1.24, 95% CI 0.92, 1.67, I2= 0, p 0.16). Duration of second stent patency was not significantly different between patients who received second SEMS versus plastic stents (WMD) 0.46, 95% CI −0.30, 1.23, I2=83%). Survival was not significantly different among patients who received plastic stents versus SEMS (WMD −1.13, 95% CI −2.33, 0.07, I2 86%, p 0.07

Conclusions According to our results, In patients with malignant biliary obstruction and occluded SEMS, a strategy of placing a plastic stent may be as effective as second SEMS. Limitations of these findings were that all studies were retrospective and heterogeneity between studies was detected for two of the outcomes.