Pre-endoscopic retrograde cholangiopancreatography (ERCP) administration of rectal indomethacin in unselected patients to reduce post-ERCP pancreatitis: A systematic review and meta-analysis
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Previous studies have reported that peri-procedural administration of rectal indomethacin reduces the risk of pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Based on these studies, gastrointestinal (GI) societies recommend prophylactic rectal indomethacin for all patients undergoing ERCP. However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to estimate the pooled relative risk (RR) of post-ERCP pancreatitis (PEP) in unselected patients who received rectal indomethacin before the ERCP (pre-ERCP) compared to patients who received pre-ERCP rectal placebo.
We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through September 1, 2017) to identify randomized control trials (RCTs) investigating the role of pre-ERCP rectal indomethacin in reducing the risk of PEP in unselected patients undergoing ERCP. The databases included Ovid, Medline, In-Process, and Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We calculated a pooled estimate of the RR of PEP in patients who received pre-ERCP rectal indomethacin compared to patients who received pre-ERCP rectal placebo. The meta-analysis was performed using the random effects model.
Six RCTs with a total of 2229 patients were included in the final meta-analysis. There were 1143 patients in the rectal indomethacin group and 1086 patients in the rectal placebo group. There were 71 events of PEP in the rectal indomethacin group and 114 events of PEP in the rectal placebo group. Pre-ERCP administration of rectal indomethacin significantly reduced the risk of PEP compared to pre-ERCP rectal placebo (RR 0.60, 95% CI, 0.45–0.80; p<0.0001). There was no heterogeneity between the studies (I2 = 0).
The results of this meta-analysis support the routine pre-ERCP administration of rectal indomethacin in unselected patients to prevent PEP.
KeywordsEndoscopic retrograde cholangiopancreatography ERCP High-risk Indomethacin NSAIDS Pancreatic stent Pancreatitis Post-ERCP pancreatitis Rectal
Garg R acquisition of data, drafting the article, final approval; Mohan BP acquisition of data, analysis and interpretation of data, drafting the article, final approval; Krishnamoorthi R revising the article, final approval; Rustagi T conception and design of the study, drafting the article, critical revision, and final approval.
Compliance with ethical standards
Conflict of interest
RG, BPM, RK, and TR declare that they have no conflicts of interest.
- 2.Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102:1781–8.Google Scholar
- 5.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;81:143–9. e9Google Scholar
- 6.Montaño Loza A, Rodriguez Lomeli X, Garcia Correa JE, et al. Effect of the administration of rectal indomethacin on amylase serum levels after endoscopic retrograde cholangiopancreatography, and its impact on the development of secondary pancreatitis episodes. Rev Esp Enferm Dig. 2007;99:330–6.CrossRefPubMedGoogle Scholar
- 9.Dumonceau JM, Andriulli A, Deviere J, et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy. 2010;42:503–15.Google Scholar
- 10.Mine T, Morizane T, Kawaguchi Y, et al. Clinical practice guideline for post-ERCP pancreatitis. J Gastroenterol. 2017;52:1013–22.Google Scholar
- 12.Levenick JM, Gordon SR, Fadden LL, et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology. 2016;150:911–7. quiz e19Google Scholar
- 14.Feng Y, Navaneethan U, Zhu X, et al. Prophylactic rectal indomethacin may be ineffective for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in general patients: a meta-analysis. Dig Endosc. 2016;29:272–80.Google Scholar
- 15.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.Google Scholar
- 21.Hosseini M, Shalchiantabrizi P, Yektaroudy K, Dadgarmoghaddam M, Salari M. Prophylactic effect of rectal indomethacin administration, with and without intravenous hydration, on development of endoscopic retrograde cholangiopancreatography pancreatitis episodes: a randomized clinical trial. Arch Iran Med. 2016;19:538–43.PubMedGoogle Scholar
- 25.Luo H, Zhao L, Leung J, et al. Routine pre-procedural rectal indometacin versus selective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial. Lancet. 2016;387:2293–301.Google Scholar