Role for Pre-ERCP Administration of Rectal Indomethacin in Unselected Patients to Prevent Post ERCP Pancreatitis: A Systematic Review and Meta-analysis

Abstract

Introduction: Previous studies have reported that peri-procedural administration of rectal indomethacin reduces the risk of pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Based on these studies, the European and Japanese GI societies recommend prophylactic rectal indomethacin for all patients undergoing ERCP. However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to estimate the pooled relative risk (RR) of post-ERCP pancreatitis (PEP) in unselected patients who received rectal indomethacin before the ERCP (pre-ERCP) compared to patients who received pre-ERCP rectal placebo. Methods: We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through May 1st, 2016) to identify randomized control trials (RCT) investigating the role of pre-ERCP rectal indomethacin in reducing the risk of PEP in unselected patients undergoing ERCP. The databases included Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We calculated a pooled estimate of the relative risk (RR) of PEP in patients who received pre-ERCP rectal indomethacin compared to patients who received pre-ERCP rectal placebo. The meta-analysis was performed using random effects model. Results: Five RCTs with a total of 1934 patients were included in the final meta-analysis. There were 996 patients in rectal indomethacin group and 938 patients in rectal placebo group. There were 58 events of PEP in the rectal indomethacin group and 71 events of PEP in rectal placebo group. Pre-ERCP administration of rectal indomethacin reduced the risk of PEP compared to pre-ERCP rectal placebo but the difference was not statistically significant (RR, 0.74, 95% CI, 0.47-1.16; p=0.19) (Figure 1). The heterogeneity between studies was low (I2=41).Figure 1Conclusion: The results of this meta-analysis do not support the routine pre-ERCP administration of rectal indomethacin in unselected patients to prevent PEP. Previous meta-analyses which supported use of NSAIDs had broad inclusion criteria which allowed them to include different NSAID medications, routes of administration, timing of NSAID administration and selected patients at high risk for PEP.