Covered Stents versus Uncovered Stents for Unresectable Malignant Biliary Strictures: A Meta-Analysis

Abstract

Aim. To summarize the covered or uncovered SEMS for treatment of unresectable malignant distal biliary obstruction, comparing the stent patency, patient survival, and incidence of adverse events between the two SEMSs. Methods. The meta-analysis search was performed independently by two of the authors, using MEDLINE, EMBASE, OVID, and Cochrane databases on all studies between 2010 and 2015. Pooled effect was calculated using either the fixed or the random effects model. Results. Statistics shows that there is no difference between SEMSs in the hazard ratio for patient survival (HR 1.04; 95% CI, 0.92–1.17; P = 0.55) and stent patency (HR 0.87, 95% CI: 0.58 to 1.30, P = 0.5). However, incidence of adverse events (OR: 0.74, 95% CI: 0.57 to 0.97, P = 0.03) showed significant different results in the covered SEMS, with dysfunctions events (OR: 0.75, 95% CI: 0.56 to 1.00, P = 0.05) playing a more important role than complications (OR: 0.87, 95% CI: 0.58 to 1.30, P = 0.50). Conclusions. Covered SEMS group had lower incidence of adverse events. There is no significant difference in dysfunctions, but covered SEMS trends to be better, with no difference in stent patency, patient survival, and complications.

Self-expandable metal stents in malignant biliary obstruction: Back to the roots with uncovered stents as the “new” standard?

“…A recent meta-analysis reported 8 studies (6 RCTs, 2 retrospective) that included a total of 1057 patients with FCSEMSs and UCSEMSs in the management of malignant distal biliary obstruction. 16 No statistical difference was observed in terms of patient survival and stent patency between both groups. The overall incidence of adverse events was significantly lower for FCSEMSs (OR, 0.74; 95% confidence interval [CI], 0.57-0.97) when dysfunction events were included (OR, 0.75; 95% CI, 0.56-1.00) but was not significant for adverse events alone.…”

Multidisciplinary Approach to Malignant Biliary Obstruction

“…Meta-analyses comparing C-SEMS with U-SEMS did not show statistical differences concerning clinical outcomes in these patients. 48,49 C-SEMS may confer a stent failure reduction rate but at the expense of increased migration rates. Controversially, a 2018 randomized multicenter study involving 158 patients with inoperable distal MBO touted a higher patency rate of U-SEMS compared with FC-SEMS (541 vs. 240 days, p ¼ 0.031), though without a significant difference in median survival.…”

“…50 There is a theoretical risk of cholecystitis and pancreatitis with C-SEMS if the stent cover obstructs the cystic duct and pancreatic duct, respectively, but this has not been observed in multiple studies. [49][50][51] Still, it is generally recommended to either avoid covering over the cystic duct with a covered stent or to use available fenestrated stent designs which have a segment of side holes so as to not occlude the cystic duct.…”

ePTFE/FEP stents for malignant biliary obstruction

“…Biliary tree obstruction may cause symptoms like jaundice, malaise, pruritus and increased risk of cholangitis and biliary sepsis 1. Biliary drainage stents are the gold standard to effectively palliate symptoms and improve quality of life 2 3. Ideally, stent should remain patent from implantation to death to minimise the need for reintervention or further hospital admissions.…”

“…Recent studies suggest that CSEMSs in biliary obstruction from cholangiocarcinoma and pancreatic head cancer are associated with better patency and less stent dysfunction than USEMSs 7 8. A meta-analysis suggested CSEMSs have fewer adverse effects 2…”