Metallic vs plastic stents to treat biliary stricture after liver transplantation: a systematic review and meta-analysis based on randomized trials

Abstract

Background and study aims The first-line approach to anastomotic biliary stricture after orthotopic liver transplantation (OLTX) involves endoscopic retrograde cholangiopancreatography (ERCP). The most widely used technique is placement of multiple plastic stents, but discussions are ongoing on the benefits of fully-covered self-expandable metallic stents (FCEMS) in this situation. This study aimed to compare results from use of plastic and metal stents to treat biliary stricture after transplantation. Patients and methods Searches were performed in the Medline, EMBASE, SciELO/LILACS, and Cochrane databases, and only randomized studies comparing the two techniques were included in the meta-analysis. Results Our study included four randomized clinical trials totaling 205 patients. No difference was observed between the stricture resolution rate (RD: 0.01; 95 %CI [−0.08 – 0.10]), stricture recurrence (RD: 0.13; 95 %CI [−0.03 – 0.28]), and adverse events (RD: −0.10; 95 %CI [−0.65 – 0.44]) between the plastic and metallic stent groups. The metallic stent group demonstrated benefits in relation to the number of ERCPs performed (MD: −1.86; 95 %CI [−3.12 to −0.6]), duration of treatment (MD: −105.07; 95 %CI [−202.38 to −7.76 days]), number of stents used (MD: −10.633; 95 %CI [−20.82 to −0.44]), and cost (average $ 8,288.50 versus $ 18,580.00, P < 0.001). Conclusions Rates of resolution and recurrence of stricture are similar, whereas the number of ERCPs performed, number of stents used, duration of treatment, and costs were lower in patients treated with FCEMS, which shows that this device is a valid option for initial treatment of post-OLTX biliary stricture.

Recent innovations in therapeutic endoscopy for pancreatobiliary diseases

“…Other studies [39][40][41] showed that CSEMSs resulted in approximately the same stricture elimination rate as PSs, but involved fewer surgical procedures. In addition, in the most recent meta-analysis, 42 when the multiple PSs group and the CSEMS group were compared, no significant differences were found in stricture elimination, restenosis, and AEs rate. On the other, the use of CSEMSs was advantageous from an economic point of view.…”

Endoscopic Management of Biliary Complications after Liver Transplant

“…[17][18][19][20] Pooled meta-analysis of 205 patients from these trials showed stricture resolution rate of 87% for SEMS versus 88% for MPS (with risk difference [RD]: 0.01; 95% confidence interval [CI] [À0.08 to 0.10]), while stricture recurrence rates were 22% for SEMS versus 10% for MPS (with RD: 0.13; 95% CI [-0.0.3 to 0.28]). 21 The average cost of ABS endoscopic therapy with FCSEMS was $8,288.50, lower compared to endoscopic therapy with MPS at $18,580. 21 The most frequent complication for FCSEMS is the risk for stent migration, which occurs in up to a third of cases.…”

“…21 The average cost of ABS endoscopic therapy with FCSEMS was $8,288.50, lower compared to endoscopic therapy with MPS at $18,580. 21 The most frequent complication for FCSEMS is the risk for stent migration, which occurs in up to a third of cases. Care must also be taken to determine the optimal length of FCSEMS, which ideally terminates 1 to 2 cm proximal to the biliary anastomotic stricture.…”

Concise Commentary: Penny Wise and Pound Foolish—Why SEMS Makes More Sense When Treating Post-anastomotic Biliary Strictures

“…(5) What is the total cost? In a recent systematic meta-analysis by Visconti et al, FCSEMS required fewer total number of ERCP procedures which translated into a lower overall cost per patient ($ 8288.50 vs. $ 18,580.00 for FCSEMS and plastic stents, respectively P < 0.001) with overall comparable adverse events [3].…”