Systematic review with network meta‐analysis: pharmacological prophylaxis against post‐<scp>ERCP</scp> pancreatitis

Akshintala, Venkata S.; Hutfless, Susan; Colantuoni, Elizabeth; Kim, Katherine; Khashab, Mouen A.; Li, Tianjing; Elmunzer, B. Joseph; Puhan, Milo A.; Sinha, Amitasha; Kamal, Ayesha; Lennon, Anne Marie; Okolo, Patrick I.; Palakurthy, Murali Krishna; Kalloo, Anthony N.; Singh, Vikesh K.

doi:10.1111/apt.12534

Cited by 66 publications

(45 citation statements)

References 76 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Treatment has been unsatisfactory with the exception of the use of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) and prophylactic pancreatic stents. A network meta-analysis based on existing randomized controlled trials (RCTs) showed that rectal NSAIDs are one of the most efficacious agents for preventing PEP [4]. However, prophylactic stent placement is not cost-effective in patients at average risk for the development of PEP [5].…”

Section: Introductionmentioning

confidence: 99%

How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis

et al. 2017

View full text Add to dashboard Cite

BackgroundAcute pancreatitis is a severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Previous meta-analyses have shown that indomethacin effectively prevents this complication; however, the data are limited. We performed a systematic review and meta-analysis to clarify the applications for rectal indomethacin.MethodsA systematic search was performed in June 2016. Human prospective, randomized, placebo-controlled trials that compared rectally administered indomethacin with a placebo for the prevention of post-ERCP pancreatitis (PEP) were included. A meta-analysis was performed using a random-effects model to assess the outcomes (PEP) using Review Manager 5.0.ResultsSeven randomized controlled trials met the inclusion criteria (n = 3013). The overall incidence of PEP was significantly lower after prophylactic administration of rectal indomethacin than after administration of the placebo (RR, 0.58, 95% CI, 0.40–0.83; P = 0.004). A subgroup analysis was performed for rectal indomethacin administration compared to a placebo in high-risk patients (RR, 0.46; 95% CI, 0.32–0.65; P < 0.00001) and average-risk patients (RR, 0.75; 95% CI, 0.46–1.22; P = 0.25) and for administration before ERCP (RR, 0.56; 95% CI, 0.39–0.79; P = 0.001) and after the procedure (RR, 0.61; 95% CI, 0.26–1.44; P = 0.26).ConclusionsThis meta-analysis indicated that prophylactic rectal indomethacin is not suitable for all patients undergoing ERCP but it is safe and effective to prevent PEP in high-risk patients. In addition, rectal indomethacin administration before ERCP is superior to its administration after ERCP for the prevention of PEP.Electronic supplementary materialThe online version of this article (doi:10.1186/s12876-017-0599-4) contains supplementary material, which is available to authorized users.

show abstract

Section: Introductionmentioning

confidence: 99%

How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis

et al. 2017

View full text Add to dashboard Cite

show abstract

“…To date, at least 48 randomized controlled studies have been reported utilizing 15 different agents with most studies including patients at average or mixed risk for post-ERCP pancreatitis. At least six studies included high-risk patient populations [30]. Drugs that have been evaluated and their efficacy are listed in Table 3.8.…”

Section: Can a Pill Prevent Post-ercp Pancreatitis?mentioning

confidence: 99%

“…There are some data suggesting that topical nitroglycerin might be beneficial. Based on a recent network meta-analysis of very limited data involving diagnostic ERCP, topical epinephrine may reduce post-ERCP pancreatitis [30].…”

Section: Can a Pill Prevent Post-ercp Pancreatitis?mentioning

confidence: 99%

Overview of ERCP Complications: Prevention and Management

Guda

Freeman

2015

ERCP and EUS

View full text Add to dashboard Cite

“…Interestingly, a network meta-analysis showed that rectal NSAIDs were superior to pancreatic duct stenting and was not inferior to the combination of rectal indomethacin and prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis [27]. A more recent network meta-analysis concluded that topical epinephrine and rectal NSAIDs were the most efficacious agents in preventing post-ERCP pancreatitis [28].…”

Section: Prevention Of Post-ercp Pancreatitismentioning

confidence: 99%

“…Perforation is a life-threatening event; prompt recognition and efficient management are very important [28]. Patients should have nothing by mouth and be administered with adequate intravenous fluids (and nutrition as necessary), and are usually given antibiotics.…”

Section: Sphincterotomy-related Perforationmentioning

confidence: 99%

Adverse events

Cotton

Elmunzer

2014

Ercp

View full text Add to dashboard Cite

Key points• Endoscopists' experience, preprocedure risk assessment, early detection, and appropriate management of the adverse events of ERCP are the keys to minimize the risks.• Acute pancreatitis is the most common serious post-ERCP adverse event. Multiple patient-and procedure-related risk factors are identified. Prophylactic pancreatic stent placement and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the rate of post-ERCP pancreatitis. The decision on using either or both methods should be individualized based on risk factors and expertise.• Perforation can occur as a result of guidewire penetration, sphincterotomy, luminal trauma, or stent migration. Conservative management is appropriate in most cases but most luminal perforations need surgical and/or endoscopic intervention.• Infection should be suspected when fever occurs following ERCP. Cholangitis when the procedure fails to provide drainage is the most worrisome infection but nosocomial infection, cholecystitis, or pancreatic sepsis can occur. Adequate drainage and antibiotic prophylaxis in high-risk patients decrease the risk.• Bleeding is considered an adverse event when it is evident after termination of ERCP. Coagulopathy is the most common risk factor. Correcting coagulopathy, endoscopic and endovascular examination and/or treatment, and surgery are the mainstay of management.• Cardiopulmonary, sedation-related, and stent-related complications are other adverse events. Rarely, death can occur as a consequence of post-ERCP complications.• The risk of medico-legal action after an adverse event is greatly reduced if the endoscopist and team communicate well and sympathetically with the patient and family before and after the procedure.

show abstract

Systematic review with network meta‐analysis: pharmacological prophylaxis against post‐ERCP pancreatitis

Cited by 66 publications

References 76 publications

How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis

How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis

Overview of ERCP Complications: Prevention and Management

Adverse events

Contact Info

Product

Resources

About