825 Early Implementation of Precut Sphincterotomy for the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP): Cochrane Collaboration Meta-Analysis of Randomized Controlled Trials

Abstract

825 Early Implementation of Precut Sphincterotomy for the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP): Cochrane Collaboration Meta-Analysis of Randomized Controlled Trials Frances TSE*, Siwar Albashir, Yuhong Yuan, Paul Moayyedi, Grigorios I. Leontiadis, Alan N. Barkun McMaster University, Hamilton, ON, Canada; McGill Univserity, Montreal, QC, Canada Background and Aim: Precut sphincterotomy, often used as a salvage technique for difficult cannulation, is considered an independent risk factor for post-ERCP complications. It remains controversial as to whether the increased risk is due to the precut itself or to the prolonged cannulation attempts prior to the use of precut. Early use of precut has been postulated to improve cannulation success and reduce the risk of PEP. We conducted a meta-analysis of randomized controlled trials (RCTs) of a strategy of early use of precut vs. a strategy of persistent attempts with conventional cannulation (CC) +/delayed use of precut for the prevention of PEP. Methods: We searched MEDLINE, EMBASE, CENTRAL, CINAHL up to September 2013. Conference proceedings from DDW, UEGW and ACG were searched. RCTs that compared early use of precut vs. persistent attempts with CC +/delayed use of precut were included. Study selection, data extraction and quality assessment were conducted independently by two authors. Primary outcome was incidence of PEP. Secondary outcomes included severity of PEP, CBD cannulation success with the randomized technique (primary cannulation success), eventual overall CBD cannulation success, bleeding, cholangitis, perforation and mortality. Revman 5.1 was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI, MandelHaenszel method; random effects model). Heterogeneity was assessed by Chi test (P!0.15) and I test (O25%). Results: Eight RCTs (1121 participants) met the inclusion criteria. Definitions of difficult cannulation were variable. The incidence of PEP in the early precut group was 4.6% compared to 7.5% in the CC group. Among patients with difficult cannulation, there was a trend favoring the early use of precut compared to persistent attempts with CC +/delayed use of precut for the prevention of PEP (RR 0.62; 95% CI 0.38-1.01; I Z0%) (Figure 1). The early use of precut was associated with a significantly higher primary cannulation success (91.0% vs. 58.7%; RR 1.64; 95% CI 1.28-2.10; I Z88%) with no significant increase in complications compared with persistent attempts with CC +/delayed use of precut. There was no significant difference in the overall CBD cannulation success between the two strategies (RR 1.00; 95% CI 0.96-1.04; I Z28%). Conclusion: In patients with difficult CBD cannulation, the early use of precut sphincterotomy by experienced endoscopists increases the primary cannulation success and does not appear to increase the risk of PEP or other complications compared to persistent attempts with conventional cannulation. Further RCTs are needed to confirm these findings.