A meta-analysis of randomized trials: immediate stent placement vs. surgical bypass in the palliative management of malignant biliary obstruction.

CONTEXT Many patients with unresectable pancreatic and peripancreatic cancer require treatment for malignant biliary obstruction. OBJECTIVES To conduct a meta-analysis of the English language literature (1985-2011) comparing immediate biliary stent placement and immediate surgical biliary bypass in patients with unresectable pancreatic and peripancreatic cancer and analyze associated hospital utilization patterns. METHODS After identifying five randomized controlled trials comparing immediate biliary stent placement and immediate surgical biliary bypass, we performed a meta-analysis for dichotomous outcomes, using a random effects model. We compared resource utilization in terms of the number of hospital days before death by reviewing high-quality literature. RESULTS Three hundred seventy-nine patients were identified. We found no statistically significant differences in success rates between the two treatments (risk ratio [RR] 0.99; 95% CI 0.93-1.05; P = 0.67). Major complications and mortality were not significantly higher after surgical bypass (RR 1.54; 95% CI 0.87-2.71; P = 0.14). Recurrent biliary obstruction was significantly less frequent after surgical bypass than after stent placement (RR 0.14; 95% CI 0.03-0.63; P < 0.01). Despite similar overall survival rates, longer survival was associated with more hospital days before death in stent patients than in surgical patients. CONCLUSION Nearly all patients with unresectable pancreatic cancer benefit from some procedure to manage biliary obstruction. Patients with low surgical risk benefit more from surgery because the risk of recurrence and subsequent hospital utilization are lower than after stent placement.