Mo1386 Comparative Effectiveness of Metal Versus Plastic Stents for Preoperative Biliary Drainage in Resectable and Borderline Resectable Distal Malignant Biliary Obstruction: a Systematic Review and Meta-Analysis

Abstract

Mo1386 Comparative Effectiveness of Metal Versus Plastic Stents for Preoperative Biliary Drainage in Resectable and Borderline Resectable Distal Malignant Biliary Obstruction: a Systematic Review and Meta-Analysis Tarun Rustagi*, Thomas Mccarty Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT; Department of Internal Medicine, Yale University School of Medicine, New Haven, CT Background: Increasing numbers of patients with resectable and borderline resectable distal malignant biliary obstruction are receiving neoadjuvant therapy, and benefit from preoperative biliary drainage (PBD). While endoscopic PBD is the preferred approach, considerable controversy exists regarding the type of endobiliary stent (plastic vs. SEMS) which should be used. The aim of this study is to perform a systematic review and structured analysis of all eligible studies to evaluate the comparative effectiveness of plastic and metal stents in the treatment of resectable or borderline resectable distal malignant biliary obstruction. Methods: Searches of MEDLINE and Embase databases were performed through November 2014. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction was performed independently by 2 authors. Measured outcomes including type of malignancy, length of hospital stay, time to surgical intervention, rate of re-ERCP, complications, survival and follow-up were compared among plastic and metal stent studies. Results: Twenty-seven studies (24 retrospective [nZ4403], 2 prospective [nZ395], one randomized controlled trial [nZ202]) were included in the analysis. Of these, a majority were resectable (nZ2931); 193 were borderline resectable, and the remaining were eventually diagnosed with inoperable or benign disease. 18 of 27 studies had patients with pancreatic cancer (nZ2490). 19 studies (nZ3133) included patients with plastic stents, 2 studies (nZ296) with metal stents, and 6 studies (nZ1571) had patients with plastic and metal stents. No controlled study compared metal vs. plastic stenting. In total, plastic stents were placed in 2496 patients and 448 patients received metal stents. The overall complication rate was significantly higher in plastic stent group compared to the metal stent patients (57.8% vs. 30.6%; p!0.0001). Cholangitis/cholestasis (p!0.0001) and other infectious complications (pZ0.0004) were more frequent in the plastic group. Pancreatitis, however, was more common in the metal stent group (pZ0.0003). Patients with plastic stents were more likely to undergo repeat ERCP compared to those with metal stents (10% vs. 6.9%; pZ0.44). Plastic stent group had a significantly longer hospitalization (14.1 vs. 7.8 days; p!0.001) and a higher mortality rate (2.3% vs. 0.22%; pZ0.0014) compared to metal stent group. There was no significant difference between the time (delay) to surgery or rates of unresectability between the two stent groups. Conclusions: Metal stents are effective and safe and may offer improved outcomes in PBD of resectable or borderline resectable distal malignant biliary obstruction. Plastic stents are associated with a higher complication rate including recurrent episodes of stent occlusion resulting in unplanned ERCPs, longer hospitalization and increased mortality.