A Bayesian Network Meta-Analysis Comparing Biliary Stent Types’ Outcome and Complications in Unresectable Malignant Biliary Obstructions

Document Type : Systematic Review and Meta-analysis


Division of Digestive Surgery, Department of Surgery, Sanglah General Hospital, Udayana University, Denpasar, Bali, Indonesia.


Objective: To conduct a network meta-analysis (NMA) in comparing biliary stents types’ outcomes and complications in unresectable MBO. Methods: The study was conducted in accordance with the PRISMA and NMA extension . Comprehensive searches of the Cochrane Library, MEDLINE, and Scopus were done analyzing randomized controlled trials that included subjects with unresectable malignant biliary obstructions that underwent biliary stents placement from any approaches. The types of stents that included were full-covered metal (FMS), partially-covered metal (PMS), uncovered metal (UMS), plastic (PLS), Iodine-125 seeds strands (IRS), antireflux (ARS), and paclitaxel-coated (PXS) stents. The outcome parameters were clinical success, median patency duration, medial survival, and early 30-day mortality. The complications included were stent occlusion, stent migration, cholangitis, cholecystitis, pancreatitis, hemorrhage, and hemobilia. The NMA will be done based on Bayesian method, Markov Chain Monte Carlo algorithm, using BUGSnet package in R studio. Transivity was controlled by methods and consistency of the NMA will be fitted by deviance information criterion. Data analysis in NMA were presented in Sucra plot, league table, and forest plot. Result: Thirty-six RCTs were included with 3502 subjects. ARS had the best clinical success and longest median patency. However, it was associated with higher rate of  complications. IRS had a good clinical success (RR 1.63; 95%CI 0.67-6.25), long median patency (MD 21.14; 95%CI -106.18 to 145.91), and high significant survival rate (MD 69.89; 95%CI 22 to 117.57) compared to others stents. It was associated unsignificant complications of cholecystitis, hemobilia, and hemorrhage. Conclusion: Iodine-125 seeds strands had the promising good outcome and tolerated complications among others and should be considered as a standard stent to be used in unresectable malignant biliary obstructions.


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