Alsakarneh Saqr, Brotherton Tim, Jaber Fouad, Madi Mahmoud Y, Numan Laith, Ahmed Mohamed, Sallam Yazan, Adam Mohammad, Dahiya Dushyant Singh, Aggarwal Pearl, Dinary Fazel
Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.
Department of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO, USA.
Gastroenterology Res. 2024 Jun;17(3):101-108. doi: 10.14740/gr1726. Epub 2024 Jun 29.
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic therapeutic modality for biliary and pancreatic diseases. Needle-knife fistulotomy (NKF) and papillotomy (NKP) are the two most commonly used rescue techniques for patients with difficult biliary cannulation. However, there remains a need for comparative studies on these approaches to inform clinical decision-making. This meta-analysis aimed to evaluate the efficacy and safety of NKF compared to NKP as a rescue technique in difficult biliary cannulation after failed conventional ERCP.
We searched PubMed, Scopus, Embase, and Web of Science databases through November 2023 to include all studies that directly compared the outcomes of NKF with NKP in difficult biliary cannulation. Single-arm studies were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data related to clinical events were calculated using the Mantel-Haenszel method within a random-effect model. The primary outcome was the biliary cannulation success rate.
Four studies with 823 patients (n = 376 NKF vs. n = 447 NKP) were included in our analysis. There was no significant difference between the two groups in biliary cannulation success rate (91.7% vs. 86.9%, respectively; OR = 1.54, 95% CI: 0.21 - 2.49, P = 0.14; I = 0%). However, the overall rate of adverse events was significantly lower in the NKF group than in the NKP group (OR = 0.46, 95% CI: 0.25 - 0.84, P = 0.01). Pancreatitis (OR = 0.23, 95% CI: 0.05 - 1.11, P = 0.07) and bleeding (OR = 1.43, 95% CI: 0.59 - 3.46, P = 0.42) were similar between the two groups. No significant differences in cholangitis, cholecystitis, perforation, or mortality were observed.
Our meta-analysis indicates comparable success rates in comparing NKF and NKP techniques for difficult biliary cannulation after failed conventional ERCP cannulation. Notably, the NKF technique significantly reduces overall adverse events compared to NKP, suggesting that NKF may be preferable due to its favorable safety profile. Additional randomized controlled trials (RCTs) are warranted to evaluate the interval benefit of an NKF technique.
内镜逆行胰胆管造影术（ERCP）是治疗胆胰疾病的重要内镜治疗方式。针刀瘘管切开术（NKF）和乳头切开术（NKP）是胆管插管困难患者最常用的两种挽救技术。然而，仍需要对这些方法进行比较研究，以为临床决策提供依据。本荟萃分析旨在评估在传统ERCP失败后，NKF作为胆管插管困难的挽救技术与NKP相比的疗效和安全性。
我们检索了截至2023年11月的PubMed、Scopus、Embase和Web of Science数据库，纳入所有直接比较NKF与NKP在胆管插管困难中结局的研究。排除单臂研究。使用随机效应模型中的Mantel-Haenszel方法计算与临床事件相关的二分数据的合并比值比（OR）和95%置信区间（CI）。主要结局是胆管插管成功率。
我们的分析纳入了4项研究，共823例患者（NKF组376例，NKP组447例）。两组胆管插管成功率无显著差异（分别为91.7%和86.9%；OR = 1.54，95% CI：0.21 - 2.49，P = 0.14；I² = 0%）。然而，NKF组的总体不良事件发生率显著低于NKP组（OR = 0.46，95% CI：0.25 - 0.84，P = 0.01）。两组胰腺炎（OR = 0.23，95% CI：0.05 - 1.11，P = 0.07）和出血（OR = 1.43，95% CI：0.59 - 3.46，P = 0.42）情况相似。未观察到胆管炎、胆囊炎、穿孔或死亡率的显著差异。
我们的荟萃分析表明，在传统ERCP插管失败后，比较NKF和NKP技术用于胆管插管困难时成功率相当。值得注意的是，与NKP相比，NKF技术显著降低了总体不良事件，这表明由于其良好的安全性，NKF可能更可取。有必要进行更多随机对照试验（RCT）来评估NKF技术的长期益处。
