A Meta-Analysis of Randomized Trials: Immediate Stent Placement vs. Surgical Bypass in the Palliative Management of Malignant Biliary Obstruction

Abstract

Context Many patients with unresectable pancreatic and peripancreatic cancer require treatment for malignant biliary obstruction. We performed a meta-analysis of randomized trials comparing immediate biliary stent placement and immediate surgical biliary bypass in patients with unresectable pancreatic and peripancreatic cancer. Objectives To conduct a meta-analysis of the English language literature (1985 through 2011) comparing those two treatments and analyze hospital utilization patterns. Methods After identifying five randomized controlled trials comparing immediate biliary stent placement and immediate surgical biliary bypass, we performed a meta-analysis for dichotomous outcomes, using a random effects model. We compared resource utilization in terms of the number of hospital days before death, by reviewing high-quality literature. Results 379 patients were identified. We found no statistically significant differences in success rates between the two treatments (risk ratio [RR], 0.99; 95% confidence interval [CI], 0.93 to 1.05, P = 0.67). Major complications and mortality were not significantly higher after surgical bypass (RR, 1.54; 95% CI, 0.87 to 2.71; P = 0.14). Recurrent biliary obstruction was significantly less frequent after surgical bypass than after stent placement (RR, 0.14; 95% CI, 0.03–0.63; P < 0.01). Despite similar overall survival rates, longer survival was associated with more hospital days before death in stent patients than in surgical patients. Conclusions Nearly all patients with unresectable pancreatic cancer benefit from some procedure to manage biliary obstruction. Patients with low surgical risk may benefit more from surgery because the risk of recurrence and subsequent hospital utilization are much lower than for stent patients.

Surgical Palliative Drainage in Un-resectable Malignant Biliary Obstruction

“…Thus, the patients with advanced un-resectable tumors should undergo palliative therapy like biliary duct decompression in order to relieve pruritus and cholestasis. Treatment of obstructive jaundice leads to dramatic improvement in quality of life of the affected patients [21][22][23][24][25][26][27][28][29].…”

Surgical management of the cases with both biliary and duodenal obstruction

“…2 Meta-analyses of studies comparing endoscopy and surgery for malignant BO revealed that recurrence of BO was significantly less in biliary bypass compared to biliary stent. 24,25 With regards to GOO recurrence, studies showed that incidence rate ranges from 0% to 4.8%. 6,7,9,10,14,15,22 In addition, Hamada et al 2 reported that dysfunction of the duodenal stent was observed in 21% of the patients.…”

Lumen apposing metal stents: A review of current uses and outcomes

“…23 When ERCP fails, percutaneous drainage, surgical bypass, and EUS-guided biliary drainage (EUS-BD) are alternative options. [24][25][26] The rates of technical and clinical success have been high with EUS-BD (86%-98% and 88%-94%, respectively), although complication rates have been high as well (9%-26%). [27][28][29][30][31] To potentially improve success, LAMS have been developed and are now being used for choledochoduodenostomy (CD), gallbladder decompression, and cholecystoenterostomy.…”