Covered Self-Expanding Metal Stents Versus Multiple Plastic Stents for Benign Biliary Strictures: An Updated Meta-Analysis of Randomized Controlled Trials

Optimal endoscopic management of benign biliary strictures (BBS) has been a matter of debate with choice of stent remaining largely at the discretion of the endoscopist. In this systematic review and meta-analysis, we compared self-expanding metal stents with multiple plastic stents for benign biliary strictures. A comprehensive search of literature from 2000 till September 2021 was done of various databases for randomized controlled trials evaluating stent placement for benign biliary strictures. Our primary aim was to compare outcomes of endoscopic therapy for BBS using covered self-expandable metal stents (cSEMS) and multiple plastic stents (MPS) in terms of stricture resolution, number of ERCP sessions, recurrence of stricture, stent migration, and moderate-severe adverse events. Eight randomized controlled trials (534 patients) were included in the meta-analysis. cSEMS were comparable to MPS for stricture resolution (risk ratio {RR}: 1.0, 95% CI: 0.89-1.08, p=1.00), recurrence of stricture (RR: 0.73, 95% CI: 0.35-1.53, p=0.13), stent migration (RR: 0.90, 95% CI: 0.54-1.52, p=0.26), and moderate-severe adverse events (RR: 1.04, 95% CI: 0.67-1.61, p=0.19) with low to moderate heterogeneity among studies. cSEMS required fewer sessions of ERCP for stricture resolution (mean difference: 1.88, 95% CI: 0.91-2.85, p<0.00001) but with significant heterogeneity among studies. No difference in stricture resolution was seen in subgroup analysis between anastomotic strictures, chronic pancreatitis, or bile duct injury. cSEMS are comparable to MPS in patients with benign biliary strictures in terms of stricture resolution, recurrence, and adverse effects, needing fewer sessions of ERCP. Larger studies comparing cost-effectiveness of cSEMS and MPS in BBS are needed.