{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,16]],"date-time":"2026-04-16T23:09:32Z","timestamp":1776380972017,"version":"3.51.2"},"reference-count":38,"publisher":"Georg Thieme Verlag KG","issue":"01","license":[{"start":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T00:00:00Z","timestamp":1774310400000},"content-version":"vor","delay-in-days":82,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Avicenna J Med"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>We aim to compare the benefits, harms, and costs of multiple plastic stents (MPS) versus covered self-expandable metallic stents (CSEMS) in the treatment of benign biliary strictures (BBS).<\/jats:p>\n                  <jats:p>A comprehensive database search through June 6, 2024 identified randomized controlled trials (RCT) involving adult patients with BBS comparing MPS to CSEMS in terms of stricture resolution, recurrence, technical success, number of required procedures and stents, treatment duration, all-cause mortality, adverse events, and stent migration. We utilized the Cochrane Risk of Bias (RoB) tool2 for study quality assessment. Meta-analysis following the random effects model was performed.<\/jats:p>\n                  <jats:p>After screening 365 references, we included 7 RCTs (high RoB) involving 594 patients. Most reported stricture etiology is chronic pancreatitis (52.4%), followed by orthotopic liver transplant (40.5%). Compared with MPS, CSEMS achieved similar efficacy and safety. However, CSEMS required fewer procedures (mean difference [MD]: \u22121.84 [\u22122.56 to \u22121.11]; I2\u2009=\u200976%) and stents (MD: \u22126.04 [\u22129.55 to \u22122.52]; I2\u2009=\u200993%), amounting for shorter duration of treatment (MD: \u2212119.02 days [\u2212137.41 to \u2212100.62]; I2\u2009=\u200996%) and savings in costs between 41 and 57% with absolute savings of 4,019$ to 9,192$ favoring CSEMS. All outcomes had a low to very low certainty of evidence (CoE), except for technical success and stricture resolution (moderate CoE).<\/jats:p>\n                  <jats:p>Our analysis suggests that CSEMSs are comparable to MPSs in terms of efficacy and safety. However, it shows that CSEMSs are more cost-effective. Sample size calculations from our analyses can guide the design of future studies to validate the safety profiles and determine the feasibility of the two modalities.<\/jats:p>","DOI":"10.1055\/s-0046-1818623","type":"journal-article","created":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T23:56:53Z","timestamp":1774396613000},"page":"016-026","source":"Crossref","is-referenced-by-count":0,"title":["Covered Self-Expandable Metallic Stents versus Multiple Plastic Stents for Benign Biliary Strictures: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis"],"prefix":"10.1055","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9052-5537","authenticated-orcid":false,"given":"Tarek","family":"Nayfeh","sequence":"additional","affiliation":[{"name":"Department of Medicine, MedStar Health Georgetown University (Baltimore) Internal Medicine Residency Program, Baltimore, Maryland, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abdul Monaem","family":"Majzoub","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tarek","family":"Aboursheid","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"Malik","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, MetroHealth, Cleveland, Ohio, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karim","family":"Osman","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Leslie","family":"Hassett","sequence":"additional","affiliation":[{"name":"Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jehan","family":"Mousa","sequence":"additional","affiliation":[{"name":"Department of Medicine, MedStar Health Georgetown University (Baltimore) Internal Medicine Residency Program, Baltimore, Maryland, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Konstantinos","family":"Malandris","sequence":"additional","affiliation":[{"name":"Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nabil","family":"Noureddin","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego School of Medicine, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Azizullah Ahmadallah","family":"Beran","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Faisal","family":"Kamal","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nasir","family":"Saleem","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"194","published-online":{"date-parts":[[2026,3,24]]},"reference":[{"issue":"03","key":"ref2","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1148\/radiol.2018172424","article-title":"Management of biliary strictures: state-of-the-art review","volume":"289","author":"B S Kapoor","year":"2018","journal-title":"Radiology"},{"issue":"01","key":"ref3","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1038\/nrgastro.2015.182","article-title":"Evaluation of indeterminate biliary strictures","volume":"13","author":"C L Bowlus","year":"2016","journal-title":"Nat Rev Gastroenterol Hepatol"},{"issue":"03","key":"ref4","doi-asserted-by":"crossref","first-page":"405","DOI":"10.14309\/ajg.0000000000002190","article-title":"ACG clinical guideline: diagnosis and management of biliary strictures","volume":"118","author":"B J Elmunzer","year":"2023","journal-title":"Am J Gastroenterol"},{"issue":"07","key":"ref5","doi-asserted-by":"crossref","first-page":"682","DOI":"10.1055\/s-0043-109865","article-title":"Efficacy of self-expandable metal stents in management of benign biliary strictures and comparison with multiple plastic stents: a meta-analysis","volume":"49","author":"M A Khan","year":"2017","journal-title":"Endoscopy"},{"issue":"02","key":"ref6","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1016\/j.gie.2019.08.037","article-title":"Long-term outcomes after temporary placement of a self-expanding fully covered metal stent for benign biliary strictures secondary to chronic pancreatitis","volume":"91","author":"S Lakhtakia","year":"2020","journal-title":"Gastrointest Endosc"},{"key":"ref7","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: an updated guideline for reporting systematic reviews","volume":"372","author":"M J 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