Meta-Analysis
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World J Gastrointest Endosc. May 16, 2014; 6(5): 200-208
Published online May 16, 2014. doi: 10.4253/wjge.v6.i5.200
Early precut sphincterotomy and the risk of endoscopic retrograde cholangiopancreatography related complications: An updated meta-analysis
Udayakumar Navaneethan, Rajesh Konjeti, Preethi GK Venkatesh, Madhusudhan R Sanaka, Mansour A Parsi
Udayakumar Navaneethan, Preethi GK Venkatesh, Madhusudhan R Sanaka, Mansour A Parsi, Section for Advanced Endoscopy and Pancreatobiliary Disorders, Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, United States
Rajesh Konjeti, Department of Medicine, University of Connecticut Health Center, Farmington, CT 06030, United States
Author contributions: Navaneethan U contributed to study concept, design, and paper revisions; Konjeti R contributed to study concept, design, paper preparation and statistical analysis; Venkatesh PGK contributed to paper preparation; Sanaka MR and Parsi MA contributed to paper preparation and critical revisions.
Correspondence to: Mansour A Parsi, MD, MPH, Head, Section for Advanced Endoscopy and Pancreatobiliary Disorders, Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, United States. parsim@ccf.org
Telephone: +1-216-4444880 Fax: +1-216-44446305
Received: September 21, 2013
Revised: March 12, 2014
Accepted: April 25, 2014
Published online: May 16, 2014
Abstract

AIM: To study the cannulation and complication rates of early pre-cut sphincterotomy vs persistent attempts at cannulation by standard approach.

METHODS: Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to February 2013. The main outcome measurements were cannulation rates and post-endoscopic retrograde cholangiopancreatography (ERCP) complications. A comprehensive systematic search of the Cochrane library, PubMed, Google scholar, Scopus, National Institutes of Health, meta-register of controlled trials and published proceedings from major Gastroenterology journals and meetings until February 2013 was conducted using keywords. All Prospective randomized controlled trials (RCT) studies which met our inclusion criteria were included in the analysis. Prospective non-randomized studies and retrospective studies were excluded from our meta-analysis. The main outcomes of interest were post-ERCP pancreatitis, overall complication rates including cholangitis, ERCP-related bleeding, perforation and cannulation success rates.

RESULTS: Seven RCTs with a total of 1039 patients were included in the meta-analysis based on selection criteria. The overall cannulation rate was 90% in the pre-cut sphincterotomy vs 86.3% in the persistent attempts group (OR = 1.98; 95%CI: 0.70-5.65). The risk of post-ERCP pancreatitis (PEP) was not different between the two groups (3.9% in the pre-cut sphincterotomy vs 6.1% in the persistent attempts group, OR = 0.58, 95%CI: 0.32-1.05). Similarly, there was no statistically significant difference between the groups for overall complication rate including PEP, cholangitis, bleeding, and perforation (6.2% vs 6.9%, OR = 0.85, 95%CI: 0.51-1.41).

CONCLUSION: This meta-analysis suggests that pre-cut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates. Early pre-cut implementation does not increase PEP complications.

Keywords: Post-cholangiopancreatography pancreatitis, Pre-cut sphincterotomy, Persistent attempts, Meta analysis

Core tip: Selective cannulation of the bile duct remains the limiting step in therapeutic post-endoscopic retrograde cholangiopancreatography (ERCP). Greater than 90% of cannulation is achieved through standard techniques. In 10% of patients, cannulation is difficult and requires additional techniques such as pre-cut sphincterotomy. Early use of pre-cut sphincterotomy is suggested as a means to prevent excessive and repetitive papillary trauma which may in turn increase the risk of post-ERCP pancreatitis. The use of pre-cut sphincterotomy has been considered to increase risk of post-ERCP complications, in particular post-ERCP pancreatitis. We studied the literature on the use of pre-cut sphincterotomy in biliary access. Our meta-analysis showed that pre-cut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates including post-ERCP pancreatitis. Early pre-cut implementation does not increase PEP complications.