Endoscopic Retrograde Cholangiopancreaticography with or withoutStenting in Patients with Pancreaticobiliary Malignancy: An Updated Metaanalysis

In order to assess the beneficial and harmful effects of biliary stenting via ERCP for pancreaticobiliary stricture confirmed or suspected to be malignant, prior to surgery, we identified trials through Pubmed (1950 to June 2013), Science Citation Index Expanded (1945 to June 2013), and EMBASE (1980 to June 2013). Three authors independently selected trials for inclusion and extracted data. The primary pre-surgical, post-surgical, and final outcome measures were mortality. The secondary outcomes were complications such as cholangitis, pancreatitis, bleeding, pancreatic fistula, intra-abdominal abscess, improvement in bilirubin, and quality of life. Dichotomous outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) based on fixed- and random-effect models. We identified three randomized trials with 634 patients undergoing pancreatico-duodenectomy; 500 patients underwent ERCP with biliary stenting and 134 had ERCP without biliary stenting prior to surgery. Pre-surgical mortality was not significantly affected by stenting (OR 3.14, 95% CI 0.12 to 79.26), while there were significantly more complications in the stented group (OR 18.41, 95% CI 2.46 to 137.85). However, postsurgical complications were significantly less in the stented group (OR 0.31, 95% CI 0.21 to 0.48). Overall mortality (OR 1.05, 95% CI 0.46 to 1.71) and complications (OR 0.31, 95% CI 0.21 to 0.48) were not significantly different in the two groups. We could not find convincing evidence to support or refute endoscopic biliary stenting on the mortality in patients with pancreaticobiliary malignancy. Large randomized trials are needed to settle the question of pre-surgical biliary stenting.