Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis

ABSTRACT

Introduction

Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP).

Areas covered

This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models.

Expert opinion

1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.

KEYWORDS:

• Distal malignant biliary strictures
• endoscopic retrograde cholangiopancreatography
• plastic stent
• metal stent
• endoscopic sphincterotomy
• post-ERCP-pancreatitis

Article highlights

• Biliary drainage with stent placement remains a mainstay for patients with unresectable DMBS.

• PEP incidence significantly increases when receiving SEMS compared to PS.

• Covered metal stents (FCSEMS and PCSEMS) are associated with a higher PEP incidence compared to USEMS, but not significantly.

• Absence of pancreatic duct dilation is closely correlated to a higher PEP incidence, when receiving transpapillary FCSEMS.

• Prophylactic pancreatic stenting should be considered for patients with covered metal stent placement.

• PEP incidence was similar between transpapillary stent and suprapapillary stent placement according to limited evidences, prospective studies with large sample are needed to re-evaluate the outcome.

• EST may have no effect on PEP prevention in DMBS patients receiving biliary stent.

Acknowledgments

The authors also acknowledge American Journal Experts (Durham, NC, USA) for assisting in the preparation of the manuscript.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.