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El Hage Chehade N, Ghoneim S, Shah S, Chahine A, Issak A, Choi AY, Moosvi Z, Chang KJ, Samarasena JB. Combination Topical Epinephrine and Non-steroidal Inflammatory Drugs in the Prevention of Post-ERCP Pancreatitis: A Systematic Review. Dig Dis Sci 2023; 68:957-968. [PMID: 35695971 DOI: 10.1007/s10620-022-07518-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/07/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The utility of combination rectal NSAID and topical epinephrine (EI) or rectal NSAID and normal saline (SI) sprayed on duodenal papilla in the prevention of post-ERCP pancreatitis (PEP) has been studied but results have been conflicting. AIMS To evaluate the benefit of using combination prophylaxis in preventing PEP. METHODS A literature search was performed using Scopus, PubMed/MEDLINE, and Cochrane databases in May 2021. Randomized controlled trials (RCTs) involving adults patients who underwent ERCP and received EI versus SI were eligible for inclusion. The pooled effect was expressed as odds ratio (OR) to assess the rate of PEP, severity of PEP, and specific adverse events. The results were pooled using Reviewer Manager 5.4 software. RESULTS Six RCTs involving 4016 patients were included in the final analysis. The EI group did not demonstrate any significant benefit over SI group in preventing PEP (OR = 1.00, 95% CI [0.68, 1.45], P = 0.98), irrespective of gender or the epinephrine concentration used. The tests for subgroup differences were not statistically significant with P-values of 0.66 and 0.28, respectively. The addition of topical epinephrine to rectal NSAID did not improve the rate of moderate to severe PEP (OR = 0.94, P = 0.86) or PEP in high-risk patients (OR = 1.14, 95%, P = 0.73). The rates of infection, including cholangitis and sepsis (OR = 0.63, P = 0.07), gastrointestinal bleeding (OR = 1.25, P = 0.56) and procedure-related death (OR = 0.71, P = 0.59) were similar between both groups. CONCLUSION The addition of topical epinephrine did not demonstrate any benefit over rectal NSAID alone in preventing PEP or reducing other procedure-related adverse events.
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Affiliation(s)
- Nabil El Hage Chehade
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sara Ghoneim
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sagar Shah
- Department of Internal Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Anastasia Chahine
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Abdulfatah Issak
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Alyssa Y Choi
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Zain Moosvi
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, 101 The City Drive S, Orange, CA, 92868, USA.
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Du F, Zhang Y, Yang X, Zhang L, Yuan W, Fan H, Ren L. Efficacy of Combined Management with Nonsteroidal Anti-inflammatory Drugs for Prevention of Pancreatitis After Endoscopic Retrograde Cholangiography: a Bayesian Network Meta-analysis. J Gastrointest Surg 2022; 26:1982-1997. [PMID: 35680777 DOI: 10.1007/s11605-022-05352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To systematically evaluate the clinical efficacy of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with other agents for preventing pancreatitis after endoscopic retrograde cholangiopanography. METHODS We carried out a literature search of random controlled trials (RCTs) on preventing post-operative pancreatitis by administration of the anti-inflammatory drugs, indomethacin and diclofenac, following endoscopic retrograde cholangiopancreatography (ERCP). The databases searched for relevant publications up to July 7, 2021, included PubMed, Cochrane Library, and Embase. We screened the literature according to inclusion criteria and analyzed the extracted data. The overall population and high-risk patient groups were analyzed, with the main outcome being the incidence of PEP. RESULTS The search identified 32 RCTs that included 15019 patients with post-ERCP pancreatitis and 9 different interventions. The results of the overall population network meta-analysis showed that NSAIDs alone, high-dose NSAIDs, and a combination of NSAIDs significantly reduced the incidence of PEP compared with placebo. However, compared with placebo, there was no statistically significant difference between the two interventions (NSAIDs + standard hydration and high-dose NSAIDs). In addition, NSAIDs + sublingual nitrates were associated with a lower incidence of PEP compared to that observed with NSAIDs alone. Probability ranking results showed that NSAIDs + sublingual nitrate had the best effect, followed by NSAIDs + standard hydration, NSAIDs + melatonin, NSAIDs + aggressive hydration, NSAIDs + somatostatin, NSAIDs alone, NSAIDs + epinephrine, high-dose NSAIDs, and placebo. In the high-risk subgroup, the results of the network meta-analysis showed that NSAIDs alone, high-dose NSAIDs, and a combination of NSAIDs showed no statistically significant difference in their ability to reduce the incidence of PEP compared with placebo. Probability ranking results showed that NSAIDs + hydration had the best effect, followed by NSAIDs + sublingual nitroglycerin and NSAIDs + aggressive hydration. CONCLUSION Of the nine interventions, NSAIDs + sublingual nitrates had considerably better efficacy than the other drugs for reducing the incidence of PEP in the overall population. In high-risk patients, NSAIDs + standard hydration may be the best preventive treatment; however, more randomized, controlled trials are needed to validate our results. TRIAL REGISTRATION Name of the registry: PROSPERO-International prospective register of systematic reviews. Unique identifying number or registration ID: CRD42021282205.
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Affiliation(s)
- Fei Du
- Department of Hepatobiliary-Pancreatic Surgery, Affiliated Hospital of Qinghai University, Xining, 810000, China.,Graduate School of Qinghai University, Xining, 810000, China
| | - Yongxuan Zhang
- Department of Hepatobiliary-Pancreatic Surgery, Affiliated Hospital of Qinghai University, Xining, 810000, China.,Graduate School of Qinghai University, Xining, 810000, China
| | - Xiaozhou Yang
- Department of Hepatobiliary-Pancreatic Surgery, Affiliated Hospital of Qinghai University, Xining, 810000, China.,Graduate School of Qinghai University, Xining, 810000, China
| | - Lingkai Zhang
- Department of Hepatobiliary-Pancreatic Surgery, Affiliated Hospital of Qinghai University, Xining, 810000, China.,Graduate School of Qinghai University, Xining, 810000, China
| | - Wencong Yuan
- Department of Hepatobiliary-Pancreatic Surgery, Affiliated Hospital of Qinghai University, Xining, 810000, China.,Graduate School of Qinghai University, Xining, 810000, China
| | - Haining Fan
- Graduate School of Qinghai University, Xining, 810000, China.,Qinghai Key Laboratory of Echinococcosis Research, Xining, 810000, China
| | - Li Ren
- Graduate School of Qinghai University, Xining, 810000, China. .,Qinghai Key Laboratory of Echinococcosis Research, Xining, 810000, China.
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Ribeiro IB, do Monte Junior ES, Miranda Neto AA, Proença IM, de Moura DTH, Minata MK, Ide E, dos Santos MEL, Luz GDO, Matuguma SE, Cheng S, Baracat R, de Moura EGH. Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review. World J Gastroenterol 2021; 27:2495-2506. [PMID: 34092971 PMCID: PMC8160616 DOI: 10.3748/wjg.v27.i20.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/30/2021] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.
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Affiliation(s)
- Igor Braga Ribeiro
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Antonio Afonso Miranda Neto
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Igor Mendonça Proença
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Mauricio Kazuyoshi Minata
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Edson Ide
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Gustavo de Oliveira Luz
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Sergio Eiji Matuguma
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Spencer Cheng
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Renato Baracat
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
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