Endoscopic placement of multiple plastic stents (MPS) is considered  first-line therapy for benign biliary strictures. Emerging evidence however, suggests that SEMS may offer advantages, including fewer endoscopic re-interventions (e.g., stent exchanges) needed to achieve clinical success (stricture resolution). However, stratified data on the various specific etiologies of benign biliary strictures such as iatrogenic injury during surgery (most common), chronic inflammatory and infectious conditions, trauma, chemotherapy-induced injury, and autoimmune diseases remain limited. The aim of this meta-analysis was to pool available published data specifically on post-cholecystectomy biliary strictures in order to evaluate the efficacy and safety of SEMS placement for this specific clinical indication.

This study protocol was published in PROSPERO under the register CRD420251239366. After a systematic review of studies identified from MEDLINE, Embase and Cochrane, we performed a single-arm proportion meta-analysis analyzing the rate of stricture resolution, stricture recurrence, adverse events, stent migration and sucessful stent removal with SEMS. We excluded studies that did not provide stratified data on the specific etiology of the benign biliary stricture. We used a random-effects model to calculate the combined proportion with 95% confidence interval (CI). Between-study heterogeneity was assessed using I² statistics.

We included 6 studies, comprising 54 patients with a post-cholecystectomy biliary stricture. The rate of SEMS stricture resolution was 82.6% (95% CI 68.9-91.1%; I²=0%), and the stricture recurrence rate was 20.5% (95% CI 11.0-34.9%; I²=0%). The adverse event rate was 30.4% (95% CI 16.1-49.8%; I²=0%), and included cholangitis (n=10), pancreatitis (n=1), solid debris in lumen (n=1), and abdominal pain (n=1). The rate of stent migration was 3.8% (95% CI 0.0-15.7%; I²=0%). Successful SEMS removal rate was 94.2% (95% CI 53.0-99.6%; I²=0%).

Previous systematic reviews / meta-analyses have reported that long-term biliary stricture resolution rates with MPS for benign etiologies range from 84% to 90%, with stricture recurrence rates varying by underlying cause. In our study, we observed a stricture resolution rate of 82.6% and a stricture recurrence rate of 20.5%. Given the non-negligible rate of adverse events (30.4%), our findings highlight the need for etiology-specific analyses before generalizing the non-inferiority of SEMS across all benign biliary strictures, as the mechanisms and pathogenesis differ and each stricture etiology may require an individualized therapeutic approach. Additionally, it must be mentioned that the included studies analysed different types of SEMS. Although there was no identified between-study heterogeneity, differences in the mechanism of each stent may have played a role in our findings, which should be interpreted with caution. Unfortunately, due to lack of data it was not possible to perform subgroup analyses stratified by SEMS type. Further studies should be conducted that are stratified by benign biliary stricture etiology in order to draw more definitive conclusions.