Endoscopy 2017; 49(07): 682-694
DOI: 10.1055/s-0043-109865
Review
© Georg Thieme Verlag KG Stuttgart · New York

Efficacy of self-expandable metal stents in management of benign biliary strictures and comparison with multiple plastic stents: a meta-analysis

Muhammad Ali Khan
1   Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
,
Todd H. Baron
2   Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
,
Faisal Kamal
1   Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
,
Bilal Ali
1   Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
,
Richard Nollan
3   University of Tennessee Health Science Center Library, Memphis, Tennessee, USA
,
Mohammad Kashif Ismail
1   Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
,
Claudio Tombazzi
1   Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
,
Everson L. A. Artifon
4   University of Sao Paulo, Sao Paulo, Brazil
,
Alessandro Repici
5   Humanitas University, Milan, Italy
,
Mouen A. Khashab
6   Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
› Author Affiliations
Further Information

Publication History

submitted 30 October 2016

accepted after revision 15 February 2017

Publication Date:
24 May 2017 (online)

Abstract

Background and study aims There is burgeoning interest in the utilization of covered self-expandable metal stents (CSEMSs) for managing benign biliary stricture (BBS). This systematic review and meta-analysis evaluated cumulative stricture resolution and recurrence rates using CSEMSs and compared performance of CSEMSs and multiple plastic stents (MPS) in BBS management.

Method Searches in several databases identified studies including ≥ 10 patients that utilized CSEMSs for BBS treatment. Weighted pooled rates were calculated for stricture resolution and recurrence. Pooled risk ratios (RRs) comparing CSEMSs with MPS were calculated for stricture resolution, stricture recurrence, and adverse events. Pooled difference in means was calculated to compare number of endoscopic retrograde cholangiopancreatographies (ERCPs) in each group. 

Results The meta-analysis included 22 studies with 1298 patients. Weighted pooled rate for BBS resolution with CSEMS was 83 % (95 % confidence limits [95 %CLs] 78 %, 87 %; I 2 = 72 %). On meta-regression analysis, resolution in chronic pancreatitis patients and post-orthotopic liver transplant patients were significant predictors of heterogeneity. Weighted pooled rate for stricture recurrence with CSEMSs was 16 % (11 %, 22 %). Overall rate of adverse events requiring intervention and/or hospitalization was 15 %. Four randomized controlled trials with 213 patients compared CSEMSs with MPS: the pooled RRs for stricture resolution, recurrence, and adverse events were 1.07 (0.97, 1.18), 0.88 (0.48, 1.63), and 1.16 (0.71, 1.88), respectively with no heterogeneity. Pooled difference in means for number of ERCPs was – 1.71 ( – 2.33, – 1.09) in favor of CSEMS.

Conclusions CSEMSs appear to have excellent efficacy in BBS management. They are as effective as MPS but require fewer ERCPs to achieve clinical success.

Appendix e1 – e2

 
  • References

  • 1 Costamagna G, Boškoski I. Current treatment of benign biliary strictures. Ann Gastroenterol 2013; 26: 37-40
  • 2 Chan CH, Telford JJ. Endoscopic management of benign biliary strictures. Gastrointest Endosc Clin N Am 2012; 22: 511-537
  • 3 Chathadi KV, Chandrasekhara V, Acosta RD. ASGE Standards of Practice Committee. et al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81: 795-803
  • 4 Davids PH, Tanka AK, Rauws EA. et al. Benign biliary strictures. Surgery or endoscopy?. Ann Surg 1993; 217: 237-243
  • 5 NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consens State Sci Statements 2002; 19: 1-26
  • 6 Costamagna G, Pandolfi M, Mutignani M. et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001; 54: 162-168
  • 7 Draganov P, Hoffman B, Marsh W. Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents. Gastrointest Endosc 2002; 55: 680-686
  • 8 Baron TH. Covered self-expandable metal stents for benign biliary tract diseases. Curr Opin Gastroenterol 2011; 27: 262-267
  • 9 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
  • 10 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008-2012
  • 11 Taddio A, Pain T, Fassos FF. et al. Quality of nonstructured and structured abstracts of original research articles in the British Medical Journal, the Canadian Medical Association Journal and the Journal of the American Medical Association. CMAJ 1994; 150: 1611-1615
  • 12 Scherer RW, Langenberg P, von Elm E. Full publication of results initially presented in abstracts. Cochrane Database Syst Rev 2007; 2: MR000005
  • 13 NIH. National Heart, Lung, and Blood Institute. Quality assessment tool for before-after (pre-post) studies with no control group. Last updated March 2014 http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/tools/before-after
  • 14 Higgins JPT, Altman DG, Sterne JAC. Cochrane handbook for systematic reviews of interventions, version 5.0.1. Available at: http://handbook.cochrane.org/chapter_8/8_assessing_risk_of_bias_in_included_studies.htm Accessed: May 30, 2016
  • 15 Guyatt GH, Oxman AD, Vist GE. et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-926
  • 16 Higgins JPT, Green S. Identifying and measuring heterogeneity. Cochrane handbook for systematic reviews of interventions, version 5.0.1. Available at: handbook.cochrane.org/chapter_9/9_5_2_identifying_and_measuring_heterogeneity.htm Accessed: May 30, 2016
  • 17 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
  • 18 Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342: d549
  • 19 Kahaleh M, Behm B, Clarke BW. et al. Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video). Gastrointest Endosc 2008; 67: 446-454
  • 20 Mahajan A, Ho H, Sauer B. et al. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc 2009; 70: 303-309
  • 21 Park DH, Lee SS, Lee TH. et al. Anchoring flap versus flared end, fully covered self-expandable metal stents to prevent migration in patients with benign biliary strictures: a multicenter, prospective, comparative pilot study (with videos). Gastrointest Endosc 2011; 73: 64-70
  • 22 Poley JW, Cahen DL, Metselaar HJ. et al. A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video). Gastrointest Endosc 2012; 75: 783-789
  • 23 Perri V, Boškoski I, Tringali A. et al. Fully covered self-expandable metal stents in biliary strictures caused by chronic pancreatitis not responding to plastic stenting: a prospective study with 2 years of follow-up. Gastrointest Endosc 2012; 75: 1271-1277
  • 24 Tarantino I, Mangiavillano B, Di Mitri R. et al. Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety. Endoscopy 2012; 44: 923-927
  • 25 Moon JH, Choi HJ, Koo HC. et al. Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos). Gastrointest Endosc 2012; 75: 1080-1085
  • 26 Kahaleh M, Brijbassie A, Sethi A. et al. Multicenter trial evaluating the use of covered self-expanding metal stents in benign biliary strictures: time to revisit our therapeutic options?. J Clin Gastroenterol 2013; 47: 695-699
  • 27 Irani S, Baron TH, Akbar A. et al. Endoscopic treatment of benign biliary strictures using covered self-expandable metal stents (CSEMS). Dig Dis Sci 2014; 59: 152-160
  • 28 Wagh MS, Chavalitdhamrong D, Moezardalan K. et al. Effectiveness and safety of endoscopic treatment of benign biliary strictures using a new fully covered self expandable metal stent. Diagn Ther Endosc 2013; 2013: 183513
  • 29 Lalezari D, Singh I, Reicher S. et al. Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks. World J Gastrointest Endosc 2013; 5: 332-339
  • 30 Devière J, Nageshwar Reddy D, Püspök A. et al. Successful management of benign biliary strictures with fully covered self-expanding metal stents. Gastroenterology 2014; 147: 385-95 ; quiz e15
  • 31 Hu B, Leung JW, Gao DJ. et al. Management of benign biliary strictures with a novel retrievable self-expandable metal stent. J Dig Dis 2014; 15: 146-153
  • 32 Martins FP, Kahaleh M, Ferrari AP. Management of liver transplantation biliary stricture: Results from a tertiary hospital. World J Gastrointest Endosc 2015; 7: 747-757
  • 33 Saxena P, Diehl DL, Kumbhari V. et al. A US multicenter study of safety and efficacy of fully covered self-expandable metallic stents in benign extrahepatic biliary strictures. Dig Dis Sci 2015; 60: 3442-3448
  • 34 Walter D, Laleman W, Jansen JM. et al. A fully covered self-expandable metal stent with antimigration features for benign biliary strictures: a prospective, multicenter cohort study. Gastrointest Endosc 2015; 81: 1197-1203
  • 35 Park JS, Lee SS, Song TJ. et al. Long-term outcomes of covered self-expandable metal stents for treating benign biliary strictures. Endoscopy 2016; 48: 440-447
  • 36 Chaput U, Scatton O, Bichard P. et al. Temporary placement of partially covered self-expandable metal stents for anastomotic biliary strictures after liver transplantation: a prospective, multicenter study. Gastrointest Endosc 2010; 72: 1167-1174
  • 37 Artifon EL, Coelho F, Frazao M. et al. A prospective randomized study comparing partially covered metal stent versus plastic multistent in the endoscopic management of patients with postoperative benign bile duct strictures: a follow-up above 5 years. Rev Gastroenterol Peru 2012; 32: 26-31
  • 38 Kaffes A, Griffin S, Vaughan R. et al. A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation. Therap Adv Gastroenterol 2014; 7: 64-71
  • 39 Haapamaki C, Kylänpää L, Udd M. et al. Randomized multicenter study of multiple plastic stents vs. covered self-expandable metallic stent in the treatment of biliary stricture in chronic pancreatitis. Endoscopy 2015; 47: 605-610
  • 40 Coté GA, Slivka A, Tarnasky P. et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: a randomized clinical trial. JAMA 2016; 315: 1250-1257
  • 41 Tarantino I, Traina M, Mocciaro F. et al. Fully covered metallic stents in biliary stenosis after orthotopic liver transplantation. Endoscopy 2012; 44: 246-250
  • 42 Mangiavillano B, Luigiano C, Tarantino I. et al. Fully covered, self-expandable metal stents for first-step endoscopic treatment of biliary leaks secondary to hepato-biliary surgery: a retrospective study. Dig Liver Dis 2013; 45: 430-432
  • 43 Tarantino I, Barresi L, Curcio G. et al. Definitive outcomes of self-expandable metal stents in patients with refractory post-transplant biliary anastomotic stenosis. Dig Liver Dis 2015; 47: 562-565
  • 44 Traina M, Tarantino I, Barresi L. et al. Efficacy and safety of fully covered self-expandable metallic stents in biliary complications after liver transplantation: a preliminary study. Liver Transpl 2009; 15: 1493-1498
  • 45 Behm B, Brock A, Clarke BW. et al. Partially covered self-expandable metallic stents for benign biliary strictures due to chronic pancreatitis. Endoscopy 2009; 41: 547-551
  • 46 Hu B, Gao DJ, Yu FH. et al. Endoscopic stenting for post-transplant biliary stricture: usefulness of a novel removable covered metal stent. J Hepatobiliary Pancreat Sci 2011; 18: 640-645
  • 47 Ryu CH, Kim MH, Lee SS. et al. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures. Korean J Gastroenterol 2013; 62: 49-54
  • 48 Kao D, Zepeda-Gomez S, Tandon P. et al. Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review. Gastrointest Endosc 2013; 77: 679-691
  • 49 Siiki A, Helminen M, Sand J. et al. Covered self-expanding metal stents may be preferable to plastic stents in the treatment of chronic pancreatitis-related biliary strictures: a systematic review comparing 2 methods of stent therapy in benign biliary strictures. J Clin Gastroenterol 2014; 48: 635-643
  • 50 Phillips MS, Bonatti H, Sauer BG. et al. Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation. Endoscopy 2011; 43: 512-517