Division of Gastroenterology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea.
Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea.
Korean J Intern Med. 2022 Mar;37(2):322-339. doi: 10.3904/kjim.2021.410. Epub 2022 Feb 16.
BACKGROUND/AIMS: Different modalities have been employed to reduce the risk and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there has been a paucity of studies comparing the efficacy of various prophylactic modalities for preventing PEP. This network meta-analysis (NMA) aimed to determine the relative efficacy of pancreatic duct stents and pharmacological modalities for preventing PEP.
We performed a systematic and comprehensive search to identify and analyze all randomized controlled studies published until June 2020 that examined the effectiveness of pancreatic duct stents, rectal non-steroidal anti-inflammatory drugs (NSAIDs) based regimens, hydration, and their combinations for the prevention of PEP. The primary outcome was the frequency of PEP. An NMA was performed to combine direct and indirect comparisons of different prophylactic modalities.
The NMA included 46 studies evaluating 18 regimens in 16,241 patients. Based on integral analysis of predictive interval plots, and expected mean ranking and surface under the cumulative ranking curve values, combination prophylaxis with indomethacin + lactated Ringer's solution (LR), followed by diclofenac + nitrate and indomethacin + normal saline, was found to be the most efficacious modality for the overall prevention of PEP. Indomethacin + LR, followed by diclofenac and pancreatic duct stents, was the most efficacious modality for high-risk groups.
Rectal NSAIDs-based combination regimens with aggressive hydration or nitrate are superior to single modalities for the prevention of PEP.
背景/目的：已经采用了不同的方式来降低内镜逆行胰胆管造影术（ERCP）后胰腺炎（PEP）的风险和严重程度。然而，比较各种预防方式预防 PEP 的疗效的研究很少。本网络荟萃分析（NMA）旨在确定胰管支架和药物预防方式预防 PEP 的相对疗效。
我们进行了系统和全面的搜索，以确定并分析截至 2020 年 6 月发表的所有随机对照研究，这些研究检查了胰管支架、直肠非甾体抗炎药（NSAIDs）为基础的方案、水化及其组合预防 PEP 的效果。主要结果是 PEP 的频率。进行 NMA 以合并不同预防方式的直接和间接比较。
NMA 纳入了 46 项研究，共纳入了 16241 名患者的 18 种方案。基于预测区间图、预期平均排序和累积排序曲线下面积的综合分析，发现吲哚美辛+乳酸林格氏液（LR）联合预防，其次是双氯芬酸+硝酸盐和吲哚美辛+生理盐水，是预防 PEP 的最有效方式。对于高危人群，吲哚美辛+LR 联合预防，其次是双氯芬酸和胰管支架，是最有效的方式。
基于直肠 NSAIDs 的联合方案与积极水化或硝酸盐联合使用，在预防 PEP 方面优于单一方式。
