Impact of Optimal Timing of Early Precut Sphincterotomy on the Risk of Endoscopic Retrograde Cholangiopancreatography Related Adverse Events: A Meta-Analysis

Abstract

Background: ERCP is an invaluable procedure in the management of pancreaticobiliary disorders. Cannulation fails in 5-20% of cases using standard techniques even in the hands of experienced endoscopists. Needle-knife precutting is the most widely used method reported to improve selective biliary cannulation success rates. However, studies have demonstrated higher complications with this technique. Two meta-analyses found that early precut sphincterotomy is associated with lower risk of post-ERCP pancreatitis (PEP) compared with persistent cannulation. The purpose of this meta-analysis is to investigate whether early precut sphincterotomy is associated with increased risk of procedure-related adverse events (PRAE), including post-ERCP pancreatitis, in comparison with persistent cannulation. Likewise, we aim to determine the optimal timing of precut sphincterotomy to prevent the development of PEP.

Methodology: :Asystematicsearchonfouronlinedatabases(Pubmed, Embase, Cochrane Controlled Trial Registry and Cochrane Library) for articles on the incidence of PRAE between early precut sphincterotomy group (EPG) and persistent cannulation group (PCG) up to May 2020. The studies were validated using the Cochrane risk-of-bias assessment tool and Newcastle Ottawa scale. Results were analyzed using Cochrane RevMan v5.3 (random-effects model). The primary endpoints were the overall incidence of PRAE and optimal time for precut sphincterotomy.

Results: Nine RCTs and 1 retrospective cohort (1,571/14,017) were included. Pooled incidence showed lower rates of PEP in EPG than in PCG (4.3% vs. 7.5%) [RR 0.60; 95% Cl 0.39-0.92; 12= 0%; Chi2= 5.97]. Subgroup analysis showed that precut sphincterotomy performed between 5-10 minutes from initial cannulation had lower rates of PEP, 32 vs. 63 (RR 0.50; 95% Cl 0.26-0.94). Although, the cumulative risk ratio of PRAE favored the EPG, it was not statistically significant [RR 0.75 (95% Cl 0.53-1.02); 12=0%].

Conclusion: This meta-analysis showed that overall rate of PRAE was not statistically different between early pre-cut sphincterotomy after failed cannulation and persistent cannulation. However, early precut sphincterotomy was associated with decreased risk of PEP. Performing precut sphincterotomy after 5 minutes, but not exceeding 10 minutes of failed biliary cannulation had less risk of post-ERCP pancreatitis.