Abstract
Background and Aim Rectal indomethacin was reported to be effective for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis. However, the preventive effect of indomethacin for average-risk patients remains unclear. Recently, some conflicting evidence was addressed by recent articles. We aimed to determine the protective role of indomethacin in PEP based on the latest available literature. Methods A systematic literature search was conducted using PubMed, Embase, Web of Science, and the Cochrane Library to identify related articles published before October 2016. Studies that evaluated the administration of indomethacin in the prevention of PEP were included in the analysis. We adopted a random-effects model to calculate the overall relative risk (RR) and 95% confidence interval (CI). Results Ten trials from an initial search were finally included in the meta-analysis. The administration of rectal indomethacin significantly reduced the incidence of PEP in consecutive ERCP population (RR, 0.63; 95% CI, 0.50–0.77). There was no significant heterogeneity across included studies (I 2 = 14.2%, P = 0.31). Further subgroup analyses also revealed that rectal indomethacin could protect the individuals at high and average risks and reduced severity of PEP. Pre-ERCP administration of indomethacin seemed to be better than the post-ERCP given. There was no evidence of significant publication bias. Conclusions Rectal administration of indomethacin is an effective approach to prevent the incidence of PEP in both high- and average-risk populations undergoing ERCP. However, more high-quality RCTs are needed to further investigate the optimal timing for the administration of indomethacin.
Highlights
Post-effective for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a serious adverse event after ERCP, with a reported incidence of 9.7% in unselected patients [1]
The relative risk (RR) of individual studies ranged from 0.28 to 1.44, and the cumulative meta-analysis by publication year showed that the rectal administration of indomethacin before or after ERCP was associated with a reduced risk of PEP in the overall population (RR = 0 63; 95% confidence interval (CI), 0.50–0.77) (Figure 2)
A high degree of heterogeneity (I2 = 63 3%, P = 0 043) was noted among patients from North America. This exhaustive meta-analysis revealed a significant reduction of PEP risk (RR = 0 48, 95%, 0.26–0.87) in patients with rectal indomethacin
Summary
Post-ERCP pancreatitis (PEP) is a serious adverse event after ERCP, with a reported incidence of 9.7% in unselected patients [1]. Based on the above evidence, the European Society for Gastrointestinal Endoscopy (ESGE) guideline (2014) recommended the administration of 100 mg of rectal indomethacin for PEP prophylaxis in patients undergoing ERCP with no contraindication [3]. Rectal indomethacin was reported to be effective for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis. Studies that evaluated the administration of indomethacin in the prevention of PEP were included in the analysis. The administration of rectal indomethacin significantly reduced the incidence of PEP in consecutive ERCP population (RR, 0.63; 95% CI, 0.50–0.77). Further subgroup analyses revealed that rectal indomethacin could protect the individuals at high and average risks and reduced severity of PEP. Rectal administration of indomethacin is an effective approach to prevent the incidence of PEP in both high- and average-risk populations undergoing ERCP. More high-quality RCTs are needed to further investigate the optimal timing for the administration of indomethacin
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