Post-endoscopic retrograde cholangiopancreatography pancreatitis prevention using topical epinephrine: systematic review and meta-analysis

Abstract

Background and study aims Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Multiple drugs and techniques have been studied for the prevention of PEP. Topical epinephrine has shown mixed results and is still not widely accepted as an alternative for prevention of PEP. We performed a systematic review and meta-analysis to evaluate the efficacy of topical epinephrine in preventing PEP.

Methods A comprehensive literature review was conducted by searching Cochrane library database, Embase and PubMed up to August 2019, to identify all studies that evaluated use of topical epinephrine alone or in conjunction with other agents for prevention of PEP. Outcomes included prevention of PEP with use of topical epinephrine and evaluation of whether addiing epinephrine provides any additional benefit in preventing PEP. All analysis was conducted using Revman 5.3.

Results Eight studies, including six randomized controlled trials and two observational studies with 4123 patients, were included in the meta-analysis. Overall, there was no difference in incidence of PEP in patients who underwent ERCP and were treated with epinephrine spray versus those who were not, RR = 0.63 (CI 0.32–1.24) with heterogeneity (I2 = 72 %). However, on a subgroup analysis, topical epinephrine significantly decreases the risk of PEP when compared to placebo alone (means no intervention was done including no rectal indomethacin)., RR = 0.32 (0.18–0.57). In another subgroup analysis, there was no statistically significant difference in using topical epinephrine along with rectal indomethacin in preventing PEP compared to rectal indomethacin alone RR = 0.87 (0.46–1.64).

Conclusion Topical epinephrine does not provide any additional benefit in preventing PEP when used in conjunction with rectal indomethacin. In subgroup analysis, topical epinephrine appeared to decrease risk of PEP in the absence of rectal indomethacin, and could be considered when rectal indomethacin is unavailable or if there is a contraindication to its use.

Publikationsverlauf

Eingereicht: 20. November 2019

Angenommen: 21. April 2020

Artikel online veröffentlicht:
21. Juli 2020

• References

• 1 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 2 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 3 Kochar B, Akshintala VS, Afghani E. et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81: 143-149.e9
• 4 Wang P, Li Z-S, Liu F. et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104: 31-40
• 5 Loperfido S, Angelini G, Benedetti G. et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48: 1-10
• 6 Yaghoobi M, Pauls Q, Durkalski V. et al. Incidence and predictors of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction undergoing biliary or dual sphincterotomy: results from the EPISOD prospective multicenter randomized sham-controlled study. Endoscopy 2015; 47: 884-890
• 7 Lella F, Bagnolo F, Colombo E. et al. A simple way of avoiding post-ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834
• 8 Sundaralingam P, Masson P, Bourke MJ. Early precut sphincterotomy does not increase risk during endoscopic retrograde cholangiopancreatography in patients with difficult biliary access: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol 2015; 13: 1722-1729.e2
• 9 Matsubayashi CO, Ribeiro IB, de Moura DTH. et al. Is endoscopic balloon dilation still associated with higher rates of pancreatitis? a systematic review and meta-analysis. Pancreas 2020; 49: 158-174
• 10 Funari MP, Ribeiro IB, de Moura DTH. et al. Adverse events after biliary sphincterotomy: Does the electric current mode make a difference? A systematic review and meta-analysis of randomized controlled trials. Clin Res Hepatol Gastroenterol 2020;
• 11 Passos ML, Ribeiro IB, de Moura DTH. et al. Efficacy and safety of carbon dioxide insufflation versus air insufflation during endoscopic retrograde cholangiopancreatography in randomized controlled trials: a systematic review and meta-analysis. Endosc Int Open 2019; 7: E487-497
• 12 Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc 2004; 59: 845-864
• 13 Mazaki T, Mado K, Masuda H. et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2014; 49: 343-355
• 14 Hauser G, Milosevic M, Stimac D. et al. Preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: what can be done?. World J Gastroenterol 2015; 21: 1069-1080
• 15 Chandrasekhara V, Khashab MA, Muthusamy VR. ASGE Standards of Practice Committee. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47
• 16 Dumonceau J-M, Andriulli A, Elmunzer BJ. et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014. Endoscopy 2014; 46: 799-815
• 17 Serrano JPR, de Moura DTH, Bernardo WM. et al. Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis. Endosc Int Open 2019; 7: E477-486
• 18 Igawa M, Miyaoka M, Saitoh T. Influence of topical epinephrine application on microcirculatory disturbance in subjects with ulcerative colitis evaluated by laser Doppler flowmetry and transmission electron microscopy. Digest Endosc 2000; 12: 126-130
• 19 Kamal A, Akshintala VS, Talukdar R. et al. A randomized trial of topical epinephrine and rectal indomethacin for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients. Am J Gastroenterol 2019; 114: 339-347
• 20 Hatami B, Kashfi SMH, Abbasinazari M. et al. Epinephrine in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a preliminary study. Case Rep Gastroenterol 2018; 12: 125-136
• 21 Xu LH, Qian JB, Gu LG. et al. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla. J Gastroenterol Hepatol 2011; 26: 1139-1144
• 22 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097
• 23 Jadad AR, Moore RA, Carroll D. et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996; 17: 1-12
• 24 Higgins JPT, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
• 25 Luo H, Wang X, Zhang R. et al. Rectal indomethacin and spraying of duodenal papilla with epinephrine increases risk of pancreatitis following endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2019; 17: 1597-1606.e5
• 26 Nakaji K, Suzumura S, Nakae Y. et al. Effects in the control of edema of the papilla of Vater by epinephrine saline irrigation after endoscopic retrograde cholangiopancreatography in an endoscopy center in Japan, 2003 to 2007: exploratory retrospective analysis to evaluate the characteristics of eligible patients with a focus on serum amylase levels. Intern Med 2009; 48: 945-952
• 27 Matsushita M, Takakuwa H, Shimeno N. et al. Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis. J Gastroenterol 2009; 44: 71-75
• 28 Ohashi A, Tamada K, Tomiyama T. et al. Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty. J Gastroenterol Hepatol 2001; 16: 568-571
• 29 Chaitanya K, Murali Krishna P, Repana K. et al. Efficacy of rectal indomethacin versus papillary epinephrine spray in prevention of post-ERCP pancreatitis. Indian J Gastroenterol 2016; 35: A93
• 30 Elmunzer BJ, Higgins PDR, Saini SD. et al. Does rectal indomethacin eliminate the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP? Post hoc efficacy and cost-benefit analyses using prospective clinical trial data. Am J Gastroenterol 2013; 108: 410-415
• 31 Park C-H, Paik WH, Park ET. et al. Aggressive intravenous hydration with lactated Ringer's solution for prevention of post-ERCP pancreatitis: a prospective randomized multicenter clinical trial. Endoscopy 2018; 50: 378-385