P0034 - The Benefit of Combination Topical Epinephrine and Rectal Indomethacin for Preventing Post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Nabil El Hage Chehade, MD¹, Sara Ghoneim, MD², Anastasia Chahine, MD³, Alexa Truong, BS⁴, Abdulfatah Issak, MD⁵, Jason Samarasena, MD^6
1MetroHealth Medical Center, Cleveland, OH; ²University of Nebraska Medical Center, Omaha, NE; ³H. H. Chao Comprehensive Digestive Disease Center, University of California Irvine, Orange, CA; ⁴University of California Irvine Medical Center, Orange, CA; ⁵Case Western Reserve University, Cleveland, OH; ⁶University of California - Irvine, Orange, CA

Introduction: Pancreatitis is the most prevalent serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Different approaches have been suggested to prevent or reduce this complication. The American Society for Gastrointestinal Endoscopy recommends the use of prophylactic rectal indomethacin in average-risk individuals. Recent studies have compared the utility of rectal indomethacin (RI) with topical epinephrine (EI) sprayed on duodenal papilla versus RI alone to prevent post-ERCP pancreatitis (PEP) with conflicting results. We performed a systematic review and meta-analysis to evaluate the benefit of using the combination prophylaxis in preventing PEP.

Methods: A literature search was performed using Scopus, PubMed/MEDLINE, and Cochrane databases in May 2021. Studies included in our meta-analysis involved adults patients undergoing ERCP who either received prophylactic RI alone versus EI. Analysis was conducted using the Mantel-Haenszel model using the odds ratio (OR) to assess the rate of PEP, severe PEP, PEP in high-risk patients and specific adverse events. The results were pooled together using Reviewer Manager 5.4 software, and heterogeneity was quantified using I² statistics.

Results: Five randomized-controlled clinical trials involving 3134 patients were included in the final analysis. Included studies were rated as moderate in terms of study design quality using the Collaboration Risk of Bias Tool and Jadad Scale. The EI group did not demonstrate any significant benefit over RI group in preventing PEP (OR 1.05, 95% CI [0.66, 1.66], P= 0.84, I²= 45%). Adding topical epinephrine to rectal indomethacin did not improve the rate of severe PEP (OR 1.66, 95% CI [0.78-3.55], P= 0.19) or PEP in high-risk patients (OR 1.14, 95% CI [0.53, 2.45], P= 0.73). Cholangitis (OR 0.52, P= 0.07), bleeding (OR 1.78, P= 0.11) and death rates (OR 0.77, P= 0.65) were similar between both groups.

Discussion: The combination of rectal indomethacin and topical epinephrine failed to demonstrate any benefit over indomethacin alone in preventing PEP, severe PEP, or decreasing specific adverse events. This is the first systematic review that investigates different pertinent parameters related to the use of topical epinephrine in combination to rectal indomethacin for prophylaxis in patients undergoing ERCP. More studies are needed as published data about this topic are sparse.




Disclosures:


Nabil El Hage Chehade, MD¹, Sara Ghoneim, MD², Anastasia Chahine, MD³, Alexa Truong, BS⁴, Abdulfatah Issak, MD⁵, Jason Samarasena, MD⁶. P0034 - The Benefit of Combination Topical Epinephrine and Rectal Indomethacin for Preventing Post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.