98 Combination Rectal Indomethacin and Topical Epinephrine Is Not Superior to Rectal Indomethacin in the Prevention of Post-ERCP Pancreatitis—A Meta-Analysis

Abstract

INTRODUCTION: Post Endoscopic Retrograde Cholangiopancreaticography Pancreatitis (PEP) remains one of the major complications despite the advances. Several medications have been used in an attempt to prevent PEP. The efficacy of rectal indomethacin (RI) and topical epinephrine (TE) has been proved. However, the role of combination of epinephrine and indomethacin in PEP prevention has not been extensively explored. We aimed to determine the efficacy of combined RI and TE compared to RI alone for PEP prevention in high risk patients. METHODS: We searched the databases of MEDLINE, EMBASE, and CENTRAL from inception to May 2019. The inclusion criteria were published randomized controlled trials comparing the efficacy of PEP prevention between patients receiving combined RI and TE vs. RI alone in high risk patients. The outcome of interest was the rate of PEP occurrence. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled risk ratio (RR) and 95% confidence intervals (CI). I2 statistics was used to assess heterogeneity among studies, with I2 >50% indicates significant heterogeneity. RESULTS: Three randomized controlled trials met our inclusion criteria and were included in the meta-analysis and reported a total of 772 and 728 patients in RI alone and combined RI and TE group, respectively (Table 1). The occurrence of PEP in combined RI and TE group is comparable to RI group with pooled RR of 1.10 (95% CI: 0.58–2.08, I2 = 47%) (Figure 1). Studies did not stratify PEP based on the severity and hence a subgroup analysis could not be performed in this meta-analysis. CONCLUSION: Based on the results from RCTs, combination of RI and TE do not give additional benefit to RI alone for PEP prevention in high risk patients for post ERCP pancreatitis. The mechanism of action of these two medications are different but the effects are not synergistic. The single use of each medication is effective to prevent PEP. Further RCTs are required to confirm our finding in high-risk patients.