Urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) vs. Conventional Approach in Acute Biliary Pancreatitis Without Cholangitis: An Updated Systematic Review and Meta-Analysis

Abstract

Gallstone disease is the common cause of acute pancreatitis. The role of early endoscopic retrograde cholangiopancreatography (ERCP) in biliary pancreatitis without cholangitis is not well-established. Thus, this study aims to compare the outcome of early ERCP with conservative management in patients with acute biliary pancreatitis without acute cholangitis. An online search of PubMed, PubMed Central, Embase, Scopus, and Clinicaltrials.gov databases was performed for relevant studies published till December 15, 2020. Statistical analysis was performed using RevMan v 5.4 (The Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen). Odds Ratio (OR) with a 95% confidence interval was used for outcome estimation. Among 2700 studies from the database search, we included four studies in the final analysis. Pooling of data showed no significant reduction in mortality (OR 0.59, 95% CI 0.32 to 1.09; p=0.09); overall complications (OR 0.56, 95% CI 0.30 to 1.01; p=0.05); new-onset organ failure (OR 1.06, 95% CI 0.65 to 1.75; p=0.81); pancreatic necrosis (OR 0.80, 95% CI 0.49 to 1.32; p=0.38); pancreatic pseudo-cyst (OR 0.44, 95% CI 0.16 to 1.24; p=0.12); ICU admission (OR 1.64, 95% CI 0.97 to 2.77; p=0.06); and pneumonia development (OR 0.81, 95% CI 0.40 to 1.65; p=0.56) by urgent ERCP comparing with conventional approach for acute biliary pancreatitis without cholangitis. Henceforth, early ERCP in acute biliary pancreatitis without cholangitis did not reduce mortality, complications, and other adverse outcomes compared to the conservative treatment.

Keywords: cholangitis; endoscopic retrograde cholangiopancreatography; meta-analysis; mortality; pancreatitis.

Figure 1. Cochrane Risk of Bias (RoBs) of included studies

Four studies were included in the analysis [7,9-11].

Figure 2. PRISMA Flow diagram

n: number; ERCP: endoscopic retrograde cholangiopancreatography

Figure 3. Forest plot comparing mortality outcome across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Four studies reported the mortality outcomes [7,9-11].

Figure 4. Forest plot comparing the occurrence of complications across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: Endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: Confidence interval; df: degrees of freedom Three studies reported the complications [7,10,11].

Figure 5. Forest plot comparing the occurrence of new-onset organ failure across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported new-onset organ failure [9-11].

Figure 6. Forest plot comparing the occurrence of pancreatic necrosis across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported pancreatic necrosis [9-11].

Figure 7. Forest plot comparing mortality outcome across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis using a random-effect model

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Four studies reported the mortality outcomes [7,9-11].

Figure 8. Forest plot comparing mortality outcome across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis excluding non-randomized controlled trial (vanSantvoort HC et al.)

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies included in the forest plot are [7,9,10].

Figure 9. Forest plot comparing mortality outcome across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis excluding studies before 2000 (Neoptolemos JP et al. 1988)

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies included in the Forest plot are [9-11].

Figure 10. Forest plot comparing the occurrence of complications across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis using a random-effect model

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported the complications [7,10,11].

Figure 11. Forest plot comparing the occurrence of complications across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis excluding studies before 2000 (Neoptolemos JP et al. 1988)

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported the complications [7,10,11].

Figure 12. Forest plot comparing the occurrence of complications across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis excluding non-randomized controlled trial (vanSantvoort HC et al.)

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported the complications [7,10,11].

Figure 13. Forest plot comparing the occurrence of new-onset organ failure across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis excluding non-randomized controlled trial (vanSantvoort HC et al.)

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported the new-onset organ failure [9-11].

Figure 14. Forest plot showing subgroup analysis on occurrence of specific organ failure across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Two studies reported specific organ failure [7,9].

Figure 15. Forest plot comparing the occurrence of pancreatic necrosis across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis excluding non-randomized controlled trial (vanSantvoort HC et al.)

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Three studies reported the pancreatic necrosis [9-11].

Figure 16. Forest plot comparing the occurrence of pancreatic pseudo-cyst across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Two studies reported pancreatic pseudo-cyst [7,9].

Figure 17. Forest plot comparing ICU admission rate across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Two studies reported ICU admission [10,11].

Figure 18. Forest plot comparing the development of pneumonia across urgent ERCP and conventional approach for acute biliary pancreatitis without cholangitis

ERCP: endoscopic retrograde cholangiopancreatography; M-H: Mantel-Haenszel; CI: confidence interval; df: degrees of freedom Two studies reported pneumonia [10,11].