Optimizing biliary drainage in malignant biliary obstruction: A systematic review and meta-analysis of transpapillary versus suprapapillary stent positioning.

4155 Background: Malignant biliary obstruction causes significant morbidity and poor survival with 5-year survival rates below 10%. Effective biliary drainage is essential to relieve cholestasis, prevent infection, and improve quality of life. Endoscopic stenting is a standard intervention, but the optimal stent position remains unclear. Placement of a stent across the duodenal papilla can lead to duodeno-biliary reflux, subsequent stent dysfunction, while suprapapillary placement may reduce reflux and improve stent patency. We performed a systematic review and meta-analysis to compare the clinical outcomes of trans-papillary versus suprapapillary biliary stent placement in patients with malignant biliary obstruction. Methods: We conducted a comprehensive search of major electronic databases to identify studies comparing suprapapillary and transpapillary biliary stent placement. All relevant studies published up to November 2025 were considered. The clinical outcomes assessed included stent occlusion, stent patency, post-ERCP pancreatitis, cholangitis, and overall adverse events. Meta-analysis was performed, and the choice of a fixed-effects or random-effects model was determined based on the presence of heterogeneity across studies. Results: A total of 14 studies, including randomized controlled trials and retrospective cohort studies, encompassing 1,169 patients, compared suprapapillary with transpapillary biliary stent placement. Suprapapillary stenting was associated with a significantly lower risk of post-ERCP pancreatitis (OR 0.23, 95% CI 0.11–0.49; I² = 0%). Stent occlusion demonstrated a non-significant trend favoring suprapapillary placement (OR 0.68, 95% CI 0.46–1.01; I² = 46%). Stent patency duration was longer with transpapillary stents (SMD 0.66, 95% CI 0.27–1.05). Rates of cholangitis were similar between groups (OR 0.86, 95% CI 0.54–1.38). Overall, adverse events were significantly lower with suprapapillary stenting (OR 0.67, 95% CI 0.47–0.94; I² = 25%). Conclusions: Suprapapillary biliary stent placement appears to be safer than transpapillary stenting, with lower rates of post-ERCP pancreatitis and overall adverse events while still providing effective biliary drainage. However, its superiority over transpapillary placement in terms of stent occlusion and stent patency remains uncertain. These findings highlight the potential advantages of suprapapillary stenting but underscore the need for further large-scale randomized controlled trials before it can be established as the standard of care.