Multiple plastic versus fully covered metal stents for managing post-liver transplantation anastomotic biliary strictures: a metaanalysis of randomized controlled trials

Abstract

Background Anastomotic biliary strictures (ABS) following liver transplantation (LT) are one of the most common complications, occurring in 4.5-32% of patients. Multiple plastic stenting (MPS) requires multiple sessions, with the associated risk, cost and patient discomfort. Fully covered self-expandable metal stents (FC-SEMS) have increasingly been used in this setting. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing the role of FC-SEMS and MPS in the treatment of ABS post-LT. Methods We conducted a bibliographic search using PubMed and EMBASE, aimed at identifying available RCTs that compared MPS to FC-SEMS in patients with ABS post LT from January 2000 to October 2017. Primary outcomes were ABS resolution and recurrence, while secondary outcomes were adverse events and number of procedures performed. Pooled estimates were calculated using random-effects models. Results Four RCTs (205 patients) were included. ABS resolution and recurrence did not differ significantly between the groups (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.43-2.56, P=0.92; and OR 2.37, 95%CI 0.54-10.38, P=0.25). The same was true for adverse events (OR 0.91, 95%CI 0.84-3.48, P=0.86) and migration rate (OR 1.31, 95%CI 0.46-3.71, P=0.61). The mean number of endoscopic retrograde cholangiopancreatography procedures was lower for FC-SEMS (mean difference [MD] -2.08). Conclusions FC-SEMS and MPS had equal ABS resolution and recurrence, although there was a trend towards a higher recurrence rate in FC-SEMS that disappeared when trials with a shorter stent indwelling time were excluding. No difference was found in overall adverse events or migration rate.

Fully covered metal stents versus plastic stents: The new kid on the block or the old standby?

“…This was reinforced by a recently published meta-analysis of these studies. 10 This meta-analysis showed a trend toward a higher rate of stricture recurrence among patients who received a cSEMS, which did not reach statistical significance. Adverse events were similar between the 2 groups, including the rate of stent migration (which was approximately 23% among patients treated with cSEMSs) and acute pancreatitis (as long as a biliary sphincterotomy was performed).…”

Fully covered self-expanding metal stents for benign biliary stricture after orthotopic liver transplant: 5-year outcomes

“…8 Although FCSEMSs has the advantage of fewer anticipated stent exchanges, a 2013 systematic review 9 and two 2017 meta-analyses 10,11 of observational data did not suggest a clear overall advantage of SEMS use over MPSs for biliary anastomotic stricture after OLT. A 2019 meta-analysis 12 including 4 RCTs concluded that FCSEMSs and MPSs had equal anastomotic biliary stricture resolution and recurrence and similar overall rates of adverse events or stent migration. A trend towards a higher stricture recurrence rate in FCSEMS disappeared when trials with shorter stent indwell time were excluded.…”

Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options

“…Meta-analyses [22,23] found SEMS and MPS had equal ABS resolution and recurrence (odds ratio 1.05, 95% confidence interval 0.43-2.56), although there was a trend towards a higher recurrence rate in SEMS. This greater stricture recurrence rate was no longer significant when trials with a shorter stent indwelling time were excluded [22], with benefits for 6 months compared to 3 months [24,25]. ESGE guidelines recommend temporary insertion of MPS for the treatment of benign ABS following orthotopic liver transplantation pending further evidence about SEMS (weak recommendation, moderate-quality evidence) [5].…”

“…Post-liver transplant, strictures can be anastomotic biliary strictures (ABSs) or non-anastomotic biliary strictures. For anastomotic biliary strictures, MPS is the gold standard [22]. Meta-analyses [22,23] found SEMS and MPS had equal ABS resolution and recurrence (odds ratio 1.05, 95% confidence interval 0.43-2.56), although there was a trend towards a higher recurrence rate in SEMS.…”

“…For anastomotic biliary strictures, MPS is the gold standard [22]. Meta-analyses [22,23] found SEMS and MPS had equal ABS resolution and recurrence (odds ratio 1.05, 95% confidence interval 0.43-2.56), although there was a trend towards a higher recurrence rate in SEMS. This greater stricture recurrence rate was no longer significant when trials with a shorter stent indwelling time were excluded [22], with benefits for 6 months compared to 3 months [24,25].…”