Preventive strategies for post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

Figure 1 PRISMA 2020 flow diagram showing the identification, screening, eligibility, and inclusion process for studies in this systematic review and meta-analysis. A total of 289 records were identified through database searching. After duplicate removal, 248 records were screened, and 154 full-text articles were assessed for eligibility. Fourteen randomized controlled trials met the inclusion criteria and were included in the quantitative synthesis.

Figure 2 Forest plot comparing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis between preventive intervention groups and control groups across the 14 included randomized controlled trials. Risk ratios with 95% confidence intervals are presented for each study. The size of each square is proportional to the study weight in the fixed-effect meta-analysis. The diamond at the bottom represents the pooled risk ratio (0.38, 95% confidence interval: 0.30-0.48), indicating a 62% relative risk reduction in favor of preventive strategies. Heterogeneity: χ² = 9.07, df = 13, P = 0.77, I² = 0%. ERCP: Endoscopic retrograde cholangiopancreatography; RR: Risk ratio; CI: Confidence interval.

Figure 3 Risk-of-bias assessment of the 14 included randomized controlled trials using the Cochrane risk-of-bias tool. Each domain was judged as having a low risk (blue plus), unclear risk (yellow question mark), or high risk (white minus) of bias. Domains assessed: Random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other potential sources of bias. The majority of trials demonstrated unclear risk in allocation concealment and blinding domains, whereas incomplete outcome data were generally at low risk of bias.

Figure 4 Funnel plot of the 14 included studies for assessing publication bias. The horizontal axis represents the log risk ratio, and the vertical axis represents the standard error of the log risk ratio. The dashed vertical line indicates the pooled effect estimate. The diagonal lines represent the pseudo-95% confidence limits around the pooled estimate, indicating the expected distribution of studies in the absence of publication bias. Visual inspection suggests some asymmetry, with smaller studies clustering predominantly on one side of the pooled estimate. Egger’s regression test yielded a statistically significant result (z = -2.54, P = 0.011), which may indicate potential publication bias or other sources of small-study effects. However, with only 14 studies included, the test has limited power, and this result should be interpreted with caution.