Guidewire Use for Prevention of Post ERCP Pancreatitis: A Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Deep biliary cannulation is important for performing therapeutic endoscopic biliary interventions. Success rates for CBD cannulation with conventional methods ranges from 50-90%, depending upon experience. Cannulation technique is believed to be pivotal in pathogenesis of post-ERCP pancreatitis (PEP) with multiple attempts increasing the risk. Multiple methods, including the use of guidewire, pre-cut technique, and medications are used to improve cannulation. A guidewire for selective cannulation may decrease the need to perform invasive techniques and PEP by improving cannulation rate. To date, the results for guidewire use for prevention of PEP and improving the rate of successful cannulation are conflicting. Therefore, we conducted meta-analysis to assess the role of guidewire use for prevention of PEP and improving cannulation rates. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, Pub Med, and recent abstracts from major conference proceedings were searched (through 10/08). RCTs comparing guidewire with conventional methods for cannulation rate and PEP were included. Standard forms were used to extract data by two independent reviewers. The effects of guidewire use were analyzed by calculating pooled estimates of PEP, hyperamylasemia, cannulation rate, need for pre-cut sphincterotomy, and pancreatic duct manipulation. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. All studies were graded by Jadad score. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Results: Six trials met inclusion criteria. Trials were of adequate quality (Jadad score ≥ 2). Guidewire cannulation demonstrated a statistically significant decrease in the odds of PEP (OR 0.61; 95% CI: 0.40-0.93, p=0.02), hyperamylasemia (OR 0.28; 95% CI: 0.16-0.46, p<0.01), and the need for pre-cut sphincterotomy (OR 0.62; 95% CI: 0.44-0.87, p=0.007) with an increase in the rate of successful cannulation (OR 2.59; 95% CI: 1.08-6.19, p=0.03) as compared to standard technique. No significant effect was observed for bleeding (OR 1.09; 95% CI: 0.47-2.51, p=0.84), time required (OR -4.59; 95% CI: -15.71-6.53, p=0.42), number of attempts (OR -5.03; 95% CI: -13.73-3.67, p=0.26) and pancreatic duct manipulation (OR 0.82; 95% CI: 0.33-2.03, p=0.67). Funnel plot revealed no publication bias. Conclusions: The use of a guidewire for CBD cannulation decreases the odds of PEP and improves the rate of successful cannulation.