Sphincterotomy with endoscopic biliary drainage for severe acute cholangitis: a meta-analysis

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Hepatology

Background:

• Acute severe obstructive cholangitis requires effective management to reduce morbidity and mortality.
• Endoscopic biliary drainage (EBD) is a key intervention, often performed with or without endoscopic sphincterotomy (ES).
• The comparative safety and efficacy of EBD with versus without ES remain debated.

Purpose of the Study:

• To evaluate the role of endoscopic sphincterotomy (ES) in conjunction with endoscopic biliary drainage (EBD) for managing acute severe obstructive cholangitis.
• To perform a meta-analysis of controlled trials comparing EBD with ES versus EBD without ES.

Main Methods:

• A systematic literature search was conducted on PubMed and Embase for controlled trials.
• Two independent reviewers selected studies and extracted data, with disagreements resolved by a third reviewer.
• Meta-analysis utilized a random effects model with Mantel-Haenszel risk ratios to assess outcomes including success rates, effectiveness, pancreatitis, bleeding, and mortality.

Main Results:

• Four controlled studies with 392 participants (201 ES, 191 Non-ES) were included.
• Drainage insertion success rate and effectiveness were similar between groups (RR: 1.00, 95% CI 0.96–1.04; RR: 1.11, 95% CI 0.73–1.7).
• While pancreatitis rates were comparable (RR: 0.73, 95% CI 0.24–2.27), EBD with ES showed a significantly higher incidence of post-procedure bleeding (RR: 8.58, 95% CI 2.03–36.34). 30-day mortality was similar.

Conclusions:

• Endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (ES) is an effective management strategy for acute obstructive cholangitis.
• Performing EBD without ES significantly reduces the risk of post-procedure bleeding.
• Critically ill patients and those with coagulopathy should ideally avoid ES during the acute phase of cholangitis.