Supra-papillary versus trans-papillary stenting for malignant biliary obstruction: an updated meta-analysis of randomized trials

Background Malignant biliary obstruction (MBO) encompasses a variety of malignant obstructions of the extrahepatic biliary tree. The relatively common occurrence of duodenobiliary reflux (DBR) in patients with standard transpapillary stent placement for palliative management raises the importance of the development of alternative methods to prevent adverse outcomes.Aims To compare supra-papillary to trans-papillary stenting in patients with MBO for stent dysfunction and adverse events.Methods PubMed, Embase, and Cochrane were systematically searched for randomized trials. Outcomes assessed included stent occlusion, stent migration, cholangitis, stent patency duration, and overall survival. Statistical analyses were conducted using R (version 4.3.1) and a random-effects model was employed.Results We found 3 randomized trials with 161 patients (80 in the supra-papilla stent group vs. 81 in the trans-papilla group). Supra-papillary stent placement was associated with significantly lower rates of stent occlusion (RR 0.76; 95% CI 0.59 to 0.97; p = 0.027), and longer cumulative duration of stent patency (MD 65.29; 95% CI 4.87 to 125.71; p = 0.03). The analyses of stent migration (p = 0.473), occurrence of cholangitis (p = 0.519), and patient survival (95% CI −1.64 to 179.38; p = 0.05) revealed no significant differences.Conclusion We found a significant improvement in stent occlusion rates and cumulative duration of stent patency favoring the supra-papilla group, with no difference for stent migration, occurrence of cholangitis, and patient survival for this comparison.