Comparative efficacy and safety of local palliative therapeutics for unresectable malignant biliary obstruction: a Bayesian network meta-analysis

Both radiofrequency ablation (RFA), photodynamic therapy (PDT), and biliary stent alone are common local palliative therapies for unresectable malignant biliary obstruction (MBO), but the best modality is uncertain. Embase, Cochrane Library, PubMed, and Web of Science were systematically searched up to 30 January 2022, for eligible studies that compared either two or all modalities in unresectable MBO. Thirty-three studies with 2974 patients were included in this study. The PDT+Stent and RFA+Stent groups had better overall survival and longer mean survival time than Stent alone (all <i>P </i>&lt; 0.05). Moreover, patients with RFA+Stent demonstrated better mean duration of stent patency (MD: 2.0, 95%CI,1.1 to 2.8, <i>P </i>&lt; 0.05) than Stent alone. The three modalities had similar postoperative mild bleeding, cholangitis, and pancreatitis (all <i>P </i>≥ 0.05). According to network ranking, PDT+Stent was most likely to provide better survival, RFA+Stent was most likely to maintain stent patency. RFA or PDT plus biliary stent is effective and safe local palliative therapy for unresectable MBO, but the current studies cannot absolutely determine which modality is the best. We should offer patients the most appropriate treatment according to the advantage of each therapy and the patient’s performance status.

射频消融术（radiofrequency ablation, RFA）、光动力疗法（photodynamic therapy, PDT）以及单纯胆道支架术均为不可切除性恶性胆道梗阻（unresectable malignant biliary obstruction, MBO）的常见局部姑息治疗手段，但目前尚无公认的最优治疗方案。本研究系统检索了截至2022年1月30日的Embase、Cochrane Library、PubMed及Web of Science数据库，筛选对比上述两种或全部疗法治疗不可切除性MBO的符合纳入标准的研究。最终共纳入33项研究，涉及2974例患者。结果显示，PDT联合支架组与RFA联合支架组的总生存期及平均生存时间均显著优于单纯支架组（所有P<0.05）。此外，RFA联合支架组的支架平均通畅时长亦优于单纯支架组（均数差MD=2.0，95%置信区间CI：1.1~2.8，P<0.05）。三种疗法术后轻度出血、胆管炎及胰腺炎的发生率均无统计学差异（所有P≥0.05）。基于网络排序分析结果，PDT联合支架最有可能改善患者生存结局，而RFA联合支架最有可能维持支架通畅性。综上，RFA或PDT联合胆道支架是治疗不可切除性MBO的安全有效的局部姑息疗法，但现有研究尚无法完全确定最优治疗方案，临床实践中应结合各疗法的优势与患者的体能状态，为患者选择最为适宜的个体化治疗方案。