No evidence to support or refute endoscopic retrograde cholangiopancreaticography (ERCP) with stenting in patients with malignant pancreaticobiliary diseases, awaiting surgery

Pancreatico-biliary malignancy includes cancers of pancreas, ampulla, duodenum, and cholangiocarcinoma. There is significant morbidity and mortality related to surgery in these patients. Studies have claimed the beneficial role of biliary decompression, which can be performed via endoscopic retrograde cholangiopancreaticography (ERCP) with stent insertion pre-surgically. The review found that pre-surgical biliary stenting via ERCP did not improve the morbidity and mortality in patients with pancreatico-biliary malignancy. Further evidence about its efficiency is needed.

Authors' conclusions: 

We could not find convincing evidence to support or refute endoscopic biliary stenting on the mortality in patients with pancreatico-biliary malignancy. Large randomised trials are needed to settle the question of pre-surgical biliary stenting.

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Background: 

Postoperative morbidity and mortality are high in patients undergoing pancreatico-duodenectomy for malignant pancreatico-biliary stricture. Different approaches have been tried to improve the outcomes, including pre-surgical biliary stenting with endoscopic retrograde cholangiopancreaticography (ERCP).

Objectives: 

To assess the beneficial and harmful effects of biliary stenting via ERCP for pancreatico-biliary stricture confirmed or suspected to be malignant, prior to surgery.

Search strategy: 

We identified trials through The Cochrane Hepato-Biliary Group Controlled Trials Register (October 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1950 to October 2006), EMBASE (1980 to October 2006), and Science Citation Index Expanded (1945 to October 2006). We also searched the references in the published papers and wrote to stent producers.

Selection criteria: 

Randomised trials comparing ERCP with biliary stenting versus ERCP without biliary stenting for pancreatico-biliary malignancy prior to surgery.

Data collection and analysis: 

Two 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.

Main results: 

We identified two randomised trials with 125 patients undergoing pancreatico-duodenectomy; 62 patients underwent ERCP with biliary stenting and 63 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 43.75, 95% CI 2.51 to 761.8). Stenting had no significant effect on the post-surgical mortality (OR 0.75, 95% CI 0.25 to 2.24). However, post-surgical complications were significantly less in the stented group (OR 0.45, 95% CI 0.22 to 0.91). Overall mortality (OR 0.81, 95% CI 0.17 to 3.89) and complications (OR 0.50, 95% CI 0.01 to 23.68) were not significantly different in the two groups.

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