Endoscopic balloon dilation versus stent placement in the management of dominant strictures in primary sclerosing cholangitis: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Dominant strictures in primary sclerosing cholangitis (PSC) remain a matter of concern as the result of the cholestatic symptoms. Treatment options include endoscopic balloon dilation (EBD) or stent placement. The objective of our study was to compare the efficacy and safety between EBD and stent placement.

METHODS

Multiple databases were searched for articles on EBD versus stent placement for treatment of dominant strictures in PSC. Preferred outcomes were subjected to systematic review and meta-analysis.

RESULTS

The number of interventions per person was 2.7 ± 0.39 with EBD and 6.5 ± 0.01 with stent placement (SD 4.55 ± 1.3 [1.48-6.6); P = .00). Clinical efficacy was 85.5% (95% Cl, 15.3-99.5; I2 = 54%) with EBD and 84.9% (95% CI, 56.6-96.1; I2 = 73%) with stent placement; relative risk (RR), 1.01 (95% CI, 0.89-1.14; I2 = 72%; P = .02). The mean percentage change in bilirubin was 14.95% among the EBD group and 42.52% among the stent placement group. Adverse events were 44.5% (95% CI, 23.3%-67.9%; I2 = 63%) with stent placement compared to the EBD, 15.0% (95% CI, 8.5-15.0; I2 = 51%); RR, 0.29 (95% CI, 0.14-0.61; P = .10). Pancreatitis incidence was 6.7% (95% CI, 3.7-11.7%; I2 = 39%) and 10.1% (95% CI, 6.5%-15.4%; I2 = 41%) with EBD and stent placement respectively; RR, 0.74 (95% CI, 0.40-1.35; P = .20). EBD caused less cholangitis, 3.2% (95% CI, 1.9%-5.4%; I2 = 0%) compared with stent placement, 16.8 (95% CI, 10.4%-25.9%; I2 = 0%); RR, 0.24 (95% CI, 0.13-0.43; P = .65). Perforation rate was 3.8% (95% CI, 1.8%-7.9%; I2 = 0%) and 3.3% (95% CI, 0.8%-11.9%; I2 = 0%) with EBD and stent placement, respectively; RR, 1.04 (95% CI, 0.36-2.99; P = .35). Bleeding occurrence was 3.4% (95% CI, 1.1%-10.2%; I2 = 0%) with EBD and 3.0% (95% CI, 0.5%-17.4%; I2 = 0%) with stent placement; RR, 0.57 (95% CI, 0.13-2.45; P = .88).

CONCLUSIONS

EBD demonstrated significantly better clinical efficacy with fewer treatment sessions. Stent placement reduces serum bilirubin more than EBD and is used in advanced PSC with severe strictures or EBD failure, potentially indicating more advanced disease.