Biliary self-expandable metallic stent for unresectable malignant distal biliary obstruction: which is better: covered or uncovered?

Self-expandable metallic stents (SEMS) are a widely accepted biliary endoprosthesis for patients with unresectable malignant distal biliary obstruction. There are two types of SEMS: covered and uncovered. Uncovered SEMS (UCSEMS) embed into the biliary wall due to their mesh structure and self-expandability, and are resistant to migration. However, the disadvantage of UCSEMS is occlusion due to tumor ingrowth (TI) via the stent mesh, and TI is the main cause of UCSEMS occlusion. To overcome this, covered SEMS (CSEMS) were developed and showed longer patency than UCSEMS. However, migration due to the non-embedded stent body is the main cause of CSEMS dysfunction. There are some randomized studies comparing CSEMS and UCSEMS; however, the results are different according to each study. From one meta-analysis, CSEMS showed longer patency than UCSEMS. A literature review revealed that covered SEMS showed longer patency than UCSEMS. Some studies cannot clearly demonstrate the superiority of CSEMS, as the CSEMS used did not prevent TI or migration. Mechanical properties of SEMS may influence the occurrence of complications. A recent clinical study comparing the Covered Wallstent and the Covered WallFlex revealed superiority of the WallFlex for the prevention of migration. Reducing the axial force and increasing the radial force may lead to good results. Migration of CSEMS should be prevented by taking into consideration the mechanical properties of stents and development of anti-migration systems.