覆膜和裸金属支架姑息性治疗远端恶性胆管梗阻的meta分析

COVERED SELF-EXPANDABLE METAL STENTS VERSUS UNCOVERED SELF-EXPANDABLE METAL STENTS IN THE PALLIATIVE TREATMENT OF DISTAL MALIGNANT BILE DUCT OBSTRUCTION:A META-ANALYSIS

目的 对比自体膨胀式覆膜金属支架（CSEMS）与自体膨胀式裸金属支架（USEMS）姑息性治疗远端恶性胆管梗阻的利与弊。方法 检索MEDLINE、EMBASE、Cochrane Library、web of knowledge、CBM、CNKI、VIP和万方数据库。纳入从1994年1月—2013年5月发表的比较CSEMS与USEMS的随机对照实验（RCT）并进行文献质量评价。运用RevMan 5.2软件对其进行meta分析。结果 12个RCT符合研究标准，包含1 296个研究对象。CSEMS与USEMS在置入后3、6及12月支架通畅率比较差异无显著性（P＞0.05）。两组发生胰腺炎、胆囊炎、胆管炎、穿孔、出血、复发胆管梗阻及病人住院时间与生存期方面比较差异无显著性（P＞0.05）。与USEMS相比，CSEMS肿瘤长入的概率显著降低（OR=0.15;95% CI 0.05-0.45;P〈0.01），但肿瘤过度生长的概率显著增高（OR=1.87;95% CI 1.06-3.30;P〈0.05），更易发生支架移位（OR=9.91;95% CI 2.98-32.95;P〈0.01）。结论 与USEMS相比，CSEMS能够显著降低远端胆管恶性梗阻病人肿瘤长入的概率，但提高了肿瘤过度生长及支架移位的概率。CSEMS未能提高支架在3、6及12月的通畅率，也不能延长病人的生存时间，未能降低病人发生并发症的概率。

Objective To compare the advantages and disadvantages between covered self-expandable metal stents （CSEMS） and uncovered self-expandable metal stents （UCSEMS） in the palliative treatment of distal malignant bile duct obstruction （DMBO）. Methods Databases of Cochrane library, MEDLINE, EMBASE, web of knowledge, CBM, CNKI, VIP and Wan Fang were searched. The papers on randomized controlled trials （RCTs） of CSEMS and UCSEMS for DMBO published during January 1994—May 2013 were collected for quality evaluation, and a meta-analysis was done using RevMan 5.2 software. Results A total of 12 RCTs including 1 296 patients were consistent with the standards of the present study. A comparison of the stent patency rates between CSEMS and UCSEMS, after 3,6 and 12 months of insertion, showed no significant differences （P〉0.05）. No differences were also noted between the two groups in terms of occurrence of pancreatitis, cholecystitis, perforation, bleeding, cholangitis, recurrent obstruction, hospitalization and patient survival （P〉0.05）. Compared with UCSEMS, tumor ingrowth rate in CSEMS was lower （OR=0.15;95%CI 0.05-0.45;P〈0.01）, but with a higher rate of tumor overgrowth （OR=1.87;95%CI 1.06-3.30;P〈0.05） and stent displacement （OR=9.91; 95%CI 2.98-32.95;P〈0.01）. Conclusion CSEMS can more dramatically reduce the ingrowth of tumors than UCSEMS in patients with malignant distal biliary obstruction, but increase the probability of tumor overgrowth and stent displacement. CSEMS fail to raise the 3-,6-and 12-month patency rates of the stent and patient survival, as well as decline complications.