Management of occluded metal stents in malignant biliary obstruction: similar outcomes with second metal stents compared to plastic stents.
BACKGROUND
Covered or uncovered self expandable metallic stents (SEMS) placed in patients with malignant biliary obstruction can occlude in 19-40 %, but optimal management is unclear.


OBJECTIVE
We sought to summarize current evidence regarding management of occluded SEMS in patients with malignant biliary obstruction.


METHODS
Two investigators independently searched Pubmed, Embase, and Web of Science using pre-defined search criteria, and reviewed bibliographies of included studies. Data were independently abstracted by two investigators, and analyzed using RevMan. We compared strategies of second SEMS versus plastic stents with respect to the following outcomes: rate of second stent re-occlusion, duration of second stent patency, and survival.


RESULTS
Ten retrospective studies met inclusion criteria for the systematic review. Management options described were placement of an uncovered SEMS (n = 125), covered SEMS (n = 106), plastic stent (n = 135), percutaneous biliary drain (n = 7), mechanical cleaning (n = 18), or microwave coagulation (n = 7). Relative risk of re-occlusion was not significantly different in patients with second SEMS compared to plastic stents (RR 1.24, 95 % CI 0.92, 1.67, I(2) = 0, p 0.16). Duration of second stent patency was not significantly different between patients who received second SEMS versus plastic stents (weighted mean difference 0.46, 95 % CI -0.30, 1.23, I(2) = 83 %). Survival was not significantly different among patients who received plastic stents versus SEMS (weighted mean difference -1.13, 95 % CI -2.33, 0.07, I(2) 86 %, p = 0.07).


CONCLUSIONS
Among patients with malignant biliary obstruction and occluded SEMS, available evidence suggests a strategy of placing a plastic stent may be as effective as second SEMS. Limitations of these findings were that all studies were retrospective and heterogeneity between studies was detected for two of the outcomes.
Division of Gastroenterology, Duke University Medical Center, Box 3913, Durham, NC 27710, USA. tilak.shah@duke.edu
Tilak
T
Shah
Svetang
S
Desai
Mahfuzul
M
Haque
Hassan
H
Dakik
Deborah
D
Fisher
D002760:Cholangiopancreatography, Endoscopic Retrograde; D001651:Cholestasis, Extrahepatic / Q000000981:diagnostic imaging / Q000209:etiology*; D003138:Common Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D041781:Jaundice, Obstructive / Q000000981:diagnostic imaging / Q000209:etiology*; D008670:Metals; D017063:Outcome Assessment, Health Care; D010969:Plastics; D015607:Stents
D008670:Metals; D010969:Plastics