Bilateral vs unilateral placement of metal stents for inoperable high-grade hilar biliary strictures: A systemic review and meta-analysis

Abstract

BACKGROUNDBilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction. No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting.AIMTo assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction.METHODSPubMed, Embase, Scopus, and Cochrane databases, as well as secondary sources (bibliographic review of selected articles and major GI proceedings), were searched through January 2019. The primary outcome was the re-intervention rate. Secondary outcomes were a technical success, early and late complications, and stent malfunction rate. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome.RESULTSA total of 9 studies were included (2 prospective Randomized Controlled Study, 5 retrospective studies, and 2 abstracts), involving 782 patients with malignant hilar obstruction. Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage (OR = 0.59, 95%CI: 0.40-0.87, P = 0.009). There was no difference in the technical success rate (OR = 0.7, CI: 0.42-1.17, P = 0.17), early complication rate (OR = 1.56, CI: 0.31-7.75, P = 0.59), late complication rate (OR = 0.91, CI: 0.58-1.41, P = 0.56) and stent malfunction (OR = 0.69, CI: 0.42-1.12, P = 0.14) between bilateral and unilateral stenting for malignant hilar biliary strictures.CONCLUSIONBilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures, with no significant difference in technical success, and early or late complication rates.

Unilateral versus Bilateral Endoscopic Nasobiliary Drainage and Subsequent Metal Stent Placement for Unresectable Malignant Hilar Obstruction: A Multicenter Randomized Controlled Trial

“…Complicated endoscopic procedure during bilateral SEMS deployment potentially increases early adverse events through unintended cholangiogram to biliary trees without drainage. Although comparable safety of bilateral and unilateral SEMS deployment was also reported [ 3 , 4 ], further studies are needed to elucidate the patient cohort who could benefit from bilateral SEMS deployment. Considering the longer tendency of TRBO in uni-SEMS group, patients with successful functional success by unilateral predrainage procedure could avoid bilateral SEMS deployment.…”

“…However, endoscopic management of malignant biliary obstruction, especially in patients with hilar stricture, is still challenging even for experienced endoscopists. Among various unmet needs for management of malignant hilar biliary obstruction [ 2 ], the superiority of bilateral or unilateral biliary drainage is still under debate [ 3 , 4 , 5 , 6 , 7 ]. Liver volume with successful biliary drainage was reported to be associated with functional success in cases with hilar biliary obstruction [ 8 ], thus bilateral drainage has a potential advantage by the preservation of larger functional liver volume compared with unilateral drainage.…”

“…Traditionally, bilateral SEMS deployment for malignant hilar biliary obstruction is not widely accepted because of the complicated endoscopic maneuver. Recently, the improvement of metallic stents allows easy bilateral SEMS deployment [ 13 , 14 , 15 , 16 ] but technical success rates of bilateral SEMS deployment still vary among studies [ 3 , 4 , 9 ]. Furthermore, it is also controversial whether this technical difficulty of bilateral SEMS deployment can lead to better long term outcomes or not.…”

Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies

“…In a recent meta-analysis involving 782 patients, bilateral biliary drainage had a lower re-intervention rate compared to unilateral drainage in patients with pCCA with no significant difference in technical success and early or late complication rates[ 61 ].…”

Efficacy and safety of EUS biliary drainage in malignant distal and hilar biliary obstruction: A comprehensive review of literature and algorithm

“…In addition, there was no difference in the TSR (OR = 0.7, CI: 0.42–1.17, P = 0.17), early complication rate (OR = 1.56, CI: 0.31–7.75, P = 0.59), late complication rate (OR = 0.91, CI: 0.58–1.41, P = 0.56), and stent malfunction (OR = 0.69, CI: 0.42–1.12, P = 0.14). [ 44 ] Needless to say, comparative studies involving EUS-BD and ERCP in MHBO are still lacking. The studies are summarized in Table 4 .…”