Double Stenting for Malignant Biliary and Duodenal Obstruction: A Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited. METHODS: A systematic literature search was performed to assess the feasibility and optimal method of double stenting for malignant duodenobiliary obstruction compared with surgical double bypass in terms of technical and clinical success, adverse events, reinterventions, and survival. Event rates with 95% confidence intervals were calculated. RESULTS: Seventy-two retrospective and 8 prospective studies published until July 2018 were included. Technical and clinical success rates of double stenting were 97% (95%–99%) and 92% (89%–95%), respectively. Clinical success of endoscopic biliary stenting was higher than that of surgery (97% [94%–99%] vs 86% [78%–92%]). Double stenting was associated with less adverse events (13% [8%–19%] vs 28% [19%–38%]) but more frequent need for reintervention (21% [16%–27%] vs 10% [4%–19%]) than double bypass. No significant difference was found between technical and clinical success and reintervention rate of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic drainage, and endoscopic ultrasound-guided biliary drainage. ERCP was associated with the least adverse events (3% [1%–6%]), followed by percutaneous transhepatic drainage (10% [0%–37%]) and endoscopic ultrasound-guided biliary drainage (23% [15%–33%]). DISCUSSION: Substantially high technical and clinical success can be achieved with double stenting. Based on the adverse event profile, ERCP can be recommended as the first choice for biliary stenting as part of double stenting, if feasible. Prospective comparative studies with well-defined outcomes and cohorts are needed.

Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction

“…However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. A recent systematic review and meta-analysis reported that endoscopic double stenting was associated with higher clinical success (97% vs. 86%) and less adverse events (13% vs. 28%), but with a more frequent need for reintervention (21% vs. 10%) compared with double surgical bypass [ 17 ]. Even though endoscopic double stenting has become the standard treatment for combined biliary and duodenal obstruction [ 18 ], minimally invasive surgical procedures such as laparoscopic gastrojejunostomy are still favored in patients with a long life expectancy, due to reports suggesting better long-term outcomes [ 19 , 20 , 21 ].…”

“…In general, the technical success rate was greatly influenced by the biliary drainage method and the proportion of type II obstructions. A systematic review and meta-analysis found that ERCP was associated with similar clinical success and less adverse events (3% vs. 23%) compared to EUS-BD for biliary drainage as part of double stenting [ 17 ]. As a result, ERCP remains the preferred treatment option when transpapillary biliary access is possible.…”

Maligne Magenausgangsstenose: Duodenalstents zur Palliation

“…92 %. Im Vergleich zur chirurgischen Doppelbypassoperation wurden bei der endoskopischen Intervention weniger Komplikationen beobachtet (13 vs. 28 %), aber Reinterventionen waren deutlich häufiger erforderlich (21 vs. 10 %) [11].…”

Long‐term outcomes of endoscopic double stenting using an anti‐reflux metal stent for combined malignant biliary and duodenal obstruction

“…However, hyperplasia is commonly associated with partially‐covered SEMS, which are widely used in EUS‐HGS 12 . Transpapillary stenting is still recommended as the first choice for biliary stenting if feasible due to the low adverse events based on a systematic review and meta‐analysis 13 …”

“…12 Transpapillary stenting is still recommended as the first choice for biliary stenting if feasible due to the low adverse events based on a systematic review and meta-analysis. 13 Although several anti-reflux metal stents (ARMS) have been investigated to prevent duodeno-biliary reflux, only Windsock-type ARMS exhibited superiority against conventional CMS. [14][15][16] Recently, a Duckbill-type metal stent (Kawasumi Duckbill Biliary Stent, SB-Kawasumi Laboratories) has been developed and its effectiveness as an ARMS has been reported.…”