Efficacy of Combining Aggressive Hydration With Rectal Indomethacin in Preventing Post-ERCP Pancreatitis: A
Dhruvil Radadiya1, Bhaumik Brahmbhatt2, Chakradhar Reddy3
1Department of Internal Medicine.
Insights
Aggressive hydration with indomethacin is the most effective intervention for preventing post-ERCP pancreatitis (PEP). For high-risk patients, a pancreatic stent is the preferred strategy for PEP prevention.
Area of Science:
- Gastroenterology
- Interventional Endoscopy
- Clinical Trial Analysis
Background:
- Postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a frequent complication of ERCP.
- Current guidelines recommend various interventions for PEP prevention, but direct comparative efficacy data from RCTs are lacking.
Purpose of the Study:
- To compare the effectiveness of guideline-recommended interventions for PEP prevention using network meta-analysis.
- To identify the optimal strategy for PEP prevention in general and high-risk populations.
Main Methods:
- Systematic search of PubMed, EMBASE, and Cochrane databases for RCTs on PEP prevention interventions.
- Inclusion of interventions such as rectal nonsteroidal anti-inflammatory drugs (NSAIDs), pancreatic stents (PS), aggressive hydration (AH), and sublingual nitrate.
- Bayesian network meta-analysis and surface under the cumulative ranking curve (SUCRA) analysis to rank interventions.
Main Results:
- Thirty-eight RCTs involving 10 different interventions were analyzed.
- All analyzed interventions demonstrated protective effects against PEP compared to controls.
- Aggressive hydration with indomethacin (AH+indomethacin) showed the highest probability (95.3%) of being the most effective intervention for general PEP prevention.
- For high-risk patients, pancreatic stent (PS) demonstrated an 80.8% probability of being the most effective strategy, with comparable efficacy to indomethacin.
Conclusions:
- Aggressive hydration with indomethacin is identified as the leading intervention for preventing PEP.
- Pancreatic stent placement is the most effective strategy for PEP prevention in high-risk patient populations.
- Further research is warranted to explore the potential benefits of combining different preventive interventions.
Abstract:
Postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography pancreatitis (ERCP). No randomized controlled trial (RCT) has compared the efficacy of the American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy recommended interventions for PEP prevention. We assessed the effectiveness of these interventions using network meta-analysis. PubMed, EMBASE, and Cochrane databases were searched to identify RCTs investigating guideline-recommended interventions and their combinations [rectal nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin or diclofenac, pancreatic stent (PS), aggressive hydration (AH), sublingual nitrate) for PEP prevention. We performed direct and Bayesian network meta-analysis, and the surface under the cumulative ranking curve to rank interventions. Subgroup network meta-analysis for high-risk populations was also performed. We identified a total of 38 RCTs with 10 different interventions. Each intervention was protective against PEP on direct and network meta-analysis compared with controls. Except AH+diclofenac and NSAIDs+ sublingual nitrate, AH+indomethacin was associated with a significant reduction in risk of PEP compared with PS [odds ratio (OR), 0.09; credible interval (CrI), 0.003-0.71], indomethcin+PS (OR, 0.09; CrI, 0.003-0.85), diclofenac (OR, 0.09; CrI, 0.003-0.65), AH (OR, 0.09; CrI, 0.003-0.65), sublingual nitrate (OR, 0.07; CrI, 0.002-0.63), and indomethacin (OR, 0.06; CrI, 0.002-0.43). AH with either rectal NSAIDs or sublingual nitrate had similar efficacy. AH+indomethacin was the best intervention for preventing PEP with 95.3% probability of being ranked first. For high-risk patients, although the efficacy of PS and indomethacin were comparable, PS had an 80.8% probability of being ranked first. AH+indomethacin seems the best intervention for preventing PEP. For high-risk patients, PS seems the most effective strategy. The potential of combination of interventions need to be explored further.
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