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
Research background

Inoperable malignant biliary strictures comes with a very high mortality rate. Self expanding metal stents (SEMS) not only offers symptomatic relief but also gives an opportunity for these patients to receive chemotherapy once bilirubin starts to trend down. Unilateral biliary SEMS have long been thought to be adequate and probably better than bilateral SEMS as it comes with lower complication rates. However, with newer endoscopic techniques and most recent prospective trials, the efficacy of bilateral SEMS has shown to be better than unilateral SEMS and with similar complication rates. This meta-analysis highlights the growing body of evidence in support of bilateral stenting versus unilateral stenting.

Research motivation

Over the past few years, newer randomized control trials (RCTs have been published showing the overall advantage of bilateral biliary stenting over unilateral stenting in a subset of patients with inoperable hilar malignant strictures. No meta-analysis was done on this topic with newer study data points.

Research objectives

We aimed to conduct a meta-analysis to compare the role of bilateral stenting vs unilateral stenting in inoperable malignant hilar strictures.

Research methods

A detailed literature search was conducted to find all the relevant articles. Two reviewers independently analyzed all the selected studies. All discrepancies were discussed independently with the third reviewer and consensus was achieved. We used Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated for each outcome.

Research results

A total of 782 patients form nine studies were included for analysis. 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.

Research conclusions

Older studies that have shown the ease of putting unilateral stenting with fewer complications over bilateral stenting in inoperable malignant hilar strictures. However, with new RCTs showing the higher success of bilateral biliary stenting with lower re-intervention rates, bilateral stenting could offer an overall advantage over unilateral stenting. Our study highlights the overall advantage of bilateral stenting over unilateral stenting.

Research perspectives

Biliary stenting is very important modality in the overall management of inoperable malignant hilar strictures. Bilateral stenting offers an advantage over unilateral stenting, however more RCT is required to further support this conclusion.