Department of Internal Medicine.
Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL.
J Clin Gastroenterol. 2022 Mar 1;56(3):e239-e249. doi: 10.1097/MCG.0000000000001523.
Postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography pancreatitis (ERCP). No randomized controlled trial (RCT) has compared the efficacy of the American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy recommended interventions for PEP prevention. We assessed the effectiveness of these interventions using network meta-analysis. PubMed, EMBASE, and Cochrane databases were searched to identify RCTs investigating guideline-recommended interventions and their combinations [rectal nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin or diclofenac, pancreatic stent (PS), aggressive hydration (AH), sublingual nitrate) for PEP prevention. We performed direct and Bayesian network meta-analysis, and the surface under the cumulative ranking curve to rank interventions. Subgroup network meta-analysis for high-risk populations was also performed. We identified a total of 38 RCTs with 10 different interventions. Each intervention was protective against PEP on direct and network meta-analysis compared with controls. Except AH+diclofenac and NSAIDs+ sublingual nitrate, AH+indomethacin was associated with a significant reduction in risk of PEP compared with PS [odds ratio (OR), 0.09; credible interval (CrI), 0.003-0.71], indomethcin+PS (OR, 0.09; CrI, 0.003-0.85), diclofenac (OR, 0.09; CrI, 0.003-0.65), AH (OR, 0.09; CrI, 0.003-0.65), sublingual nitrate (OR, 0.07; CrI, 0.002-0.63), and indomethacin (OR, 0.06; CrI, 0.002-0.43). AH with either rectal NSAIDs or sublingual nitrate had similar efficacy. AH+indomethacin was the best intervention for preventing PEP with 95.3% probability of being ranked first. For high-risk patients, although the efficacy of PS and indomethacin were comparable, PS had an 80.8% probability of being ranked first. AH+indomethacin seems the best intervention for preventing PEP. For high-risk patients, PS seems the most effective strategy. The potential of combination of interventions need to be explored further.
内镜逆行胰胆管造影术后胰腺炎 (PEP) 是内镜逆行胰胆管造影术 (ERCP) 最常见的并发症。没有随机对照试验 (RCT) 比较过美国胃肠内镜学会和欧洲胃肠内镜学会推荐的预防 PEP 的干预措施的疗效。我们使用网络荟萃分析评估了这些干预措施的有效性。我们检索了 PubMed、EMBASE 和 Cochrane 数据库，以确定调查指南推荐的干预措施及其组合[直肠非甾体抗炎药 (NSAIDs)：吲哚美辛或双氯芬酸、胰腺支架 (PS)、积极水化 (AH)、舌下硝酸盐]预防 PEP 的 RCT。我们进行了直接和贝叶斯网络荟萃分析，并绘制累积排序曲线下面积来对干预措施进行排名。还对高危人群进行了亚组网络荟萃分析。我们共确定了 38 项 RCT 和 10 种不同的干预措施。与对照组相比，每种干预措施在直接和网络荟萃分析中均能预防 PEP。除 AH+双氯芬酸和 NSAIDs+舌下硝酸盐外，与 PS 相比，AH+吲哚美辛可显著降低 PEP 风险[比值比 (OR)，0.09；可信区间 (CrI)，0.003-0.71]，吲哚美辛+PS (OR，0.09；CrI，0.003-0.85)、双氯芬酸 (OR，0.09；CrI，0.003-0.65)、AH (OR，0.09；CrI，0.003-0.65)、舌下硝酸盐 (OR，0.07；CrI，0.002-0.63) 和吲哚美辛 (OR，0.06；CrI，0.002-0.43)。AH 联合直肠 NSAIDs 或舌下硝酸盐的疗效相似。AH+吲哚美辛预防 PEP 的效果最好，有 95.3%的概率排名第一。对于高危患者，虽然 PS 和吲哚美辛的疗效相当，但 PS 有 80.8%的概率排名第一。AH+吲哚美辛似乎是预防 PEP 的最佳干预措施。对于高危患者，PS 似乎是最有效的策略。需要进一步探讨干预措施联合应用的潜力。
