GENERAL AND SUPPORTIVE CARE Malignant distal biliary obstruction: A systematic review and meta-analysis of endoscopic and surgical bypass results Alan C. Moss a, * ,c , Eva Morris b,d , Jan Leyden a,c , Padraic MacMathuna a,c a Gastrointestinal Unit, Mater Misericordiae University Hospital, Eccles Street, Dublin 1, Ireland b Academic Unit of Epidemiology & Health Services Research, University of Leeds, Arthington House, Cookridge Hospital, Leeds, West Yorkshire LS16 6QB, UK Received 30 August 2006; revised 24 October 2006; accepted 24 October 2006 Summary Background: Surgical bypass and endoscopic stents are available for palliative bypass of malig- nant distal biliary obstruction. Aim: Comparison of reported outcomes in randomized controlled trials (RCTs) which included surgery, endoscopic plastic stents or endoscopic metal stents in palliative relief of malignant distal biliary obstruction. Methods: Systematic review and meta-analysis of published literature and conference proceed- ings review to June 2006. Results: We found 24 studies, containing 2436 patients, which met our inclusion criteria. Endoscopic stenting with plastic stents (three studies) is associated with a lower risk of complications (RR 0.60, 95% CI 0.45–0.81), but a higher risk of recurrent biliary obstruction (RR 18.59, 95% CI 5.33 –64.86) than traditional surgical bypass. Self-expanding metal stents (seven studies) are associated with a significantly reduced risk of recurrent biliary obstruction at 4 months (RR 0.44, 95% CI 0.3, 0.63), or prior to death or end of study (RR 0.52, 95% CI 0.39–0.69), but are not superior to plastic stents in terms of technical success, KEYWORDS Cancer; Biliary; Pancreas; Cholangiocarcinoma; Randomized controlled trials; Meta-analysis 0305-7372/$ - see front matter  c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctrv.2006.10.006 * Corresponding author. Present address: Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA. Tel.: +1 617 667 8651; fax: +1 617 667 1010. E-mail addresses: amoss@bidmc.harvard.edu (A.C. Moss), eva.morris@nycris.leedsth.nhs.uk (E. Morris), jleyden@eircom.net (J. Leyden), pmacmathuna@mater.ie (P. MacMathuna). c Tel.: +353 1 8032366; fax: +353 1 8034770. d Tel.: +113 3924174. Cancer Treatment Reviews (2007) 33, 213– 221 available at www.sciencedirect.com journal homepage: www.elsevierhealth.com/journals/ctrv