Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 14, 2019; 25(34): 5210-5219
Published online Sep 14, 2019. doi: 10.3748/wjg.v25.i34.5210
Bilateral vs unilateral placement of metal stents for inoperable high-grade hilar biliary strictures: A systemic review and meta-analysis
Munish Ashat, Sumant Arora, Jagpal S Klair, Christopher A Childs, Arvind R Murali, Frederick C Johlin
Munish Ashat, Sumant Arora, Arvind R Murali, Frederick C Johlin, Division of Gastroenterology and Hepatology, University of Iowa Hospital and Clinics, Iowa City, IA 52242, United States
Jagpal S Klair, Section of Gastroenterology, Seattle, WA 98111, United States
Christopher A Childs, Hardin Library University of Iowa Hospital and Clinics, Iowa City, IA 52242, United States
Author contributions: Ashat M designed the study, acquisition, and analyzation of the data and writing the manuscript; Arora S acquisition of data and analyzing the data; Klair JS manuscript preparation; Childs CA acquisition of data; Murali AR interpretation of data, revising the manuscript and final approval; Johlin FC interpretation of data, revising the manuscript and final approval.
Conflict-of-interest statement: No conflict of interest to declare. No financial support was received for the study.
Data sharing statement: No additional data is available.
PRISMA 2009 Checklist statement: This manuscript was prepared and revised according to the PRISMA 2009 checklist.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jagpal S Klair, MD, Doctor, Academic Fellow, The Section of Gastroenterology and the Digestive Disease Institute, Virginia Mason 1100 Ninth Avenue, Seattle, WA 98111, United States.
Telephone: +1-504-6161210 Fax: +1-319-3848559
Received: March 23, 2019
Peer-review started: March 25, 2019
First decision: April 11, 2019
Revised: July 14, 2019
Accepted: August 7, 2019
Article in press: August 7, 2019
Published online: September 14, 2019

Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction. No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting.


To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction.


PubMed, Embase, Scopus, and Cochrane databases, as well as secondary sources (bibliographic review of selected articles and major GI proceedings), were searched through January 2019. The primary outcome was the re-intervention rate. Secondary outcomes were a technical success, early and late complications, and stent malfunction rate. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome.


A total of 9 studies were included (2 prospective Randomized Controlled Study, 5 retrospective studies, and 2 abstracts), involving 782 patients with malignant hilar obstruction. Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage (OR = 0.59, 95%CI: 0.40-0.87, P = 0.009). There was no difference in the technical success rate (OR = 0.7, CI: 0.42-1.17, P = 0.17), early complication rate (OR = 1.56, CI: 0.31-7.75, P = 0.59), late complication rate (OR = 0.91, CI: 0.58-1.41, P = 0.56) and stent malfunction (OR = 0.69, CI: 0.42-1.12, P = 0.14) between bilateral and unilateral stenting for malignant hilar biliary strictures.


Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures, with no significant difference in technical success, and early or late complication rates.

Keywords: Metal stent, Hilar biliary stricture, Re-intervention rate, Technical success rate

Core tip: Biliary drainage is useful to control jaundice and cholangitis in patients with inoperable malignant hilar strictures. No consensus guidelines are available to decide if bilateral stenting has any advantage over unilateral stenting. This meta-analysis adds to the growing body of evidence that bilateral stenting is technically feasible with similar early and late complications and leads to lower re-intervention rates.