Post written by Giuseppe Vanella, MD, from the Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, and Chiara Coluccio, MD, from the Gastroenterology Department, Morgagni-Pierantoni Hospital, Forlì, Italy.

Our study delves into the pivotal topic of biliary stent selection in the management of distal malignant biliary obstruction (dMBO). Specifically, we compared outcomes of fully covered (FC) and partially covered (PC) self-expandable metal stents (SEMSs).

We embarked on this study because of the dearth of high-quality evidence guiding selection between SEMSs. Although the superior performance of SEMSs has overshadowed plastic stenting in terms of patency and clinical success, a definitive consensus on optimal SEMS design remains elusive.

Initial data began to suggest that the covered design versus the uncovered design increases time to recurrent biliary obstruction (RBO). However, we lack direct evidence comparing FC and PC designs, which are typically mixed in studies. Our study aimed to fill this gap by providing a systematic review and meta-analysis to compare safety and efficacy of these 2 SEMS designs.

Our findings uncovered several crucial insights. There was no significant difference in the overall rate of adverse events between FC-SEMSs and PC-SEMSs, encompassing post-ERCP pancreatitis, cholecystitis, and bleeding. This challenges the notion that the bare portion of PC-SEMSs might prevent the former 2 and promote the latter. The 2 stent designs behave similarly regarding these events, as they are mostly related to the high radial force of metal design rather than mesh covering.

Moreover, we found that the total rate of RBO did not significantly differ between the designs, as a slightly higher rate of migration in FC-SEMSs is paired with a slightly increased risk of ingrowth in PC-SEMSs.

Yet, notably, PC-SEMSs demonstrated a significantly longer time to RBO than FC-SEMSs, suggesting a potential advantage in terms of extended stent patency.

Our study indicates that PC-SEMSs and FC-SEMSs might offer comparable safety profiles. FC-SEMSs might provide easier removability (especially in the case of unconfirmed pathological diagnosis), but PC-SEMSs might potentially confer a longer duration of stent patency, a critical factor in palliative care of patients with dMBO.

Our study emphasizes the importance of considering time to events, such as RBO, alongside event rates when evaluating stent performance. For all these reasons, our findings underscore the need for randomized controlled trials to confirm these observations and establish robust guidelines for stent selection in the management of dMBO. We encourage readers to delve into our article to gain deeper insights into this clinically relevant and evolving field.

Graphical Abstract

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