| Objective: To evaluate the value of endoscopic biliary stenting and biliary bypass in the treatment of malignant biliary obstruction,so as to provide reference for the treatment of malignant obstructive jaundice in clinical practice.Methods : First,make a plan to determine the criteria for inclusion and exclusion of this study.The subject of this study was a patient with an unresectable tumor who developed biliary obstruction and was older than 18 years of age.Study types include randomized clinical trials,cohort studies,and case-control studies.Regardless of blindness,publication status,country of origin and language.The intervention measures are compared endoscopic stent placement with biliary bypass surgery.Confirmation of search results was performed in databases such as Embase,Pub Med,Cochrane Central Register of Controlled Trials(CENTRAL),CNKI,Wanfang Medical Network,Weipu Periodical Integration Service Platform,and China Biomedical Document Service System(CBM).Manual search at the same time.The retrieved documents were strictly selected according to the inclusion exclusion criteria,and data were extracted.The search,screening,and data extraction processeswere conducted simultaneously by two investigators,and the dissenting part was discussed and decided,and an agreement was reached with a third party when necessary.The quality of the final screened articles was evaluated using Cochrane risk assessment tools and NOS scales.Revman 5.3 software was used to analyze the data,heterogeneity tests were completed,forest plot were produced,and the results were analyzed.Results: Finally,13 trials were included.Of the 13 studies,4 were RCTs,all of which were in English.The publication period was 1988-2006.The other 9 were retrospective studies,and published in 2003-2017.There was no statistical difference between endoscopic treatment and surgery in terms of success rate of treatment(RCT: OR=1.06,95% Cl: 0.48,2.32,p=0.89;retrospective study: OR=0.67,95% Cl: 0.18,2.44,p=0.54)and 30-day mortality(RCT:OR=0.54,95%Cl:0.27,1.07,p=0.08;retrospective study:OR=0.75,95%Cl:0.26,2.17,p=0.59).Treatment-related mortality was higher in the surgical group(RCT: OR=0.19,95% Cl: 0.05,0.69,p P=0.01;retrospective OR=0.27,95% Cl :0.10,0.71,p=0.008).In the incidence of complications,there were fewer total complications of endoscopic therapy(RCT: OR = 0.40,95% Cl: 0.24,0.68,p = 0.0006;retrospective study: OR =0.26,95% Cl: 0.13,0.49,p <0.0001),and less early complications(OR = 0.39,95% Cl: 0.25,0.60,p <0.0001),but the late complications of endoscopic therapy are high(OR=6.65,95% Cl: 3.07,14.41,p<0.00001).The incidence of cholangitis after endoscopic stent placement was higher than that of surgery.Biliary bypass had a higher incidence of pneumonia and hemorrhage.Therewas no difference between the two treatment methods in the incidence of pancreatitis and intestinal obstruction.Recurrent jaundice was more likely to occur after endoscopic stent placement(RCT: OR=20.05,95% Cl:6.59,61.02,p<0.00001;retrospective study: OR=4.51,95% Cl : 2.08,9.79,p=0.0001).In gastric outlet obstruction,the incidence of endoscopic group was higher(OR =2.22,95% Cl: 1.10,4.49,p = 0.03).The average length of hospital stay was shorter after endoscopic treatment(RCT:MD=-7.43,95%Cl:-10.03,-4.83,p< 0.00001;retrospective study: MD =-7.95,95%Cl:-13.21,-2.69,p =0.003).Conclusion: Endoscopic treatment is as beneficial as surgical treatment.Endoscopic treatment has low overall complications and early complications.The average length of stay is shorter,but it is prone to recurrent jaundice and increase the number of hospitalizations.Patients with long-term survival are recommended to use biliary bypass surgery,if necessary,combined with gastrojejunostomy(double bypass),if the patient is expected to have a short survival,endoscopic stent placement is recommended. |
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