No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial

Eur Radiol. 2020 Jan;30(1):175-185. doi: 10.1007/s00330-019-06374-7. Epub 2019 Aug 5.

Abstract

Objective: To investigate whether covered stents show a higher efficacy than uncovered stents in percutaneous treatment of malignant hilar biliary obstruction.

Methods: Patients with obstructive jaundice caused by an unresectable hilar malignancy were included after failed endoscopic intervention in a prospective randomized trial comparing expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE-FEP)-covered nitinol stents with uncovered nitinol stents. Exclusion criteria were as follows: primary tumors existing more than 3 months, a biliodigestive anastomosis, previous stenting, and a Karnofsky score of less than 50. Safety, clinical success, and adjuvant chemotherapy were compared as well as occlusion rate, patency, and survival.

Results: A total of 120 patients were included. One patient was post hoc excluded. Fourteen patients who died within 7 days and one patient without patency data were excluded from patency analysis. Serious adverse events (p = 0.4), 30-day mortality (p = 0.5), and clinical success (p = 0.8) were equivalent for both stent groups. Twenty-one out of 61 (34%) patients in the covered and 24/58 (41%) in the uncovered stent groups received adjuvant chemotherapy (p = 0.5). Occlusion rate was 54% (27/50) in the covered stent group and 57% (31/54) in the uncovered stent group (p = 0.8). Median patency was 229 days (95% CI 113-345) for covered stents and 130 days (95% CI 75-185) for uncovered stents (p = 0.1). Median survival in patients with covered stents was 79 days (95% CI 52-106) and with uncovered stents 92 days (95% CI 60-124) (p = 0.3).

Conclusion: In malignant hilar biliary obstruction, there is no evidence that ePTFE-FEP-covered stents are superior to uncovered stents in terms of safety, clinical success, adjuvant chemotherapy, patency, or survival.

Key points: • Percutaneous palliation of hilar biliary obstruction is feasible with both uncovered and covered stents. • Clinical success in terms of bilirubin decrease and adjuvant chemotherapy is achievable with both stents. • Thirty-day mortality is considerable when stenting is also offered to patients with a low performance status.

Keywords: Biliary; Jaundice; Neoplasms; Obstruction; Stents.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Biliary Tract Surgical Procedures / instrumentation*
  • Cholestasis / etiology
  • Cholestasis / mortality
  • Cholestasis / surgery*
  • Coated Materials, Biocompatible / therapeutic use
  • Female
  • Humans
  • Jaundice, Obstructive / etiology
  • Jaundice, Obstructive / surgery*
  • Liver Neoplasms / complications
  • Liver Neoplasms / mortality
  • Liver Neoplasms / therapy*
  • Male
  • Middle Aged
  • Palliative Care / methods
  • Polytetrafluoroethylene / analogs & derivatives
  • Prospective Studies
  • Stents* / adverse effects

Substances

  • Coated Materials, Biocompatible
  • fluorinated ethylene propylene
  • Polytetrafluoroethylene