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

Abstract Background: Malignant biliary obstruction was typically diagnosed at an advanced stage due to painless jaundice. Stent placement is the therapy of choice in this set of patients. Radiofrequency ablation is an ablative therapy which has been well recognized for treating malignant biliary strictures. This meta-analysis aims to help to better understand the safety and efficacy of biliary Radiofrequency ablation combined with stent placement. Methods: Five databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and China National Knowledge Infrastructure) were searched for randomized controlled trials and observational studies up to April 2020. Results: The mean difference in survival time was 54.87 days (95% confidence interval CI, 34.6-75.14), meaning patients performed with radiofrequency ablation benefit more. Reconstructed Kaplan-Meier data showed improved survival in joint intervention with RFA (hazard ratio, 1.39; 95%CI, 1.34-1.75; P < .001). However, no survival benefit was observed in the extrahepatic distal cholangiocarcinoma. With regard to patency time, the mean difference was 42.88 days (95%CI, 34.02-51.37). Reconstructed Kaplan-Meier data showed improved survival in the radiofrequency ablation treated group (hazard ratio, 1.629; 95%CI, 1.35-1.96; P < .001). Concerning postoperative complications such as abdominal pain, cholangitis and pancreatitis, our analysis did not show a significant difference between the radiofrequency ablation treatment group and the controls. Conclusion: Radiofrequency ablation plus stent resulted in improved survival and stent patency, with longer median survival and patency time than stent alone.

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Endoscopic ultrasound-guided biliary drainage for distal malignant obstruction: a systematic review and meta-analysis of randomized trials

Endoscopy International Open ◽

10.1055/a-0998-8129 ◽

2019 ◽

Vol 07 (11) ◽

pp. E1563-E1573 ◽

Cited By ~ 9

Author(s):

Corey S. Miller ◽

Alan N. Barkun ◽

Myriam Martel ◽

Yen-I Chen

Keyword(s):

Biliary Drainage ◽

Biliary Obstruction ◽

Randomized Trials ◽

Clinical Success ◽

Meta Analysis ◽

Malignant Biliary Obstruction ◽

First Line ◽

First Line Therapy ◽

Catheter Dysfunction ◽

Distal Malignant Biliary Obstruction

Abstract Background and study aims Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is increasingly used for distal malignant biliary obstruction, yet its safety and efficacy compared to endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) remain unclear. We performed a meta-analysis to improve our understanding of the role of EUS-BD in this patient population. Methods We searched Embase, MEDLINE, CENTRAL, and ISI Web of Knowledge through September 2018 for randomized controlled trials (RCTs) comparing EUS-BD to ERCP-BD or PTBD as treatment of distal malignant biliary obstruction. Risk ratios (RRs) with 95 % confidence intervals (CIs) were combined using random effects models. The primary outcome was risk of stent/catheter dysfunction requiring reintervention. Results Of six trials identified, three (n = 222) compared EUS-BD to ERCP-BD for first-line therapy; three others (n = 132) evaluated EUS-BD versus PTBD after failed ERCP-BD. EUS-BD was associated with a decreased risk of stent/catheter dysfunction overall (RR, 0.39; 95 %CI 0.27 – 0.57) and in planned subgroup analysis when compared to ERCP (RR, 0.41; 95 %CI 0.23 – 0.74) or PTBD (RR, 0.37, 95 %CI 0.22 – 0.61). Compared to ERCP, EUS was associated with a decreased risk of post-procedure pancreatitis (RR, 0.12; 95 %CI 0.01 – 0.97). No differences were noted in technical or clinical success. Conclusions In a meta-analysis of randomized trials comparing EUS-BD to conventional biliary drainage modalities, no difference in technical or clinical success was observed. Importantly, EUS-BD was associated with decreased risks of stent/catheter dysfunction when compared to both PTBD and ERCP, and decreased post-procedure pancreatitis when compared to ERCP, suggesting the potential role for EUS-BD as an alternative first-line therapy in distal malignant biliary obstruction.

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