Efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

Abstract

Objective To assess the comparative efficacy of different methods for difficult biliary cannulation in endoscopic retrograde cholangio-pancreatography (ERCP) through a network meta-analysis. Methods Randomized controlled trials (RCTs) that compared the efficacy of different adjunctive methods (early or late needle-knife technique, pancreatic guidewire-assisted technique, pancreatic stent-assisted technique, transpancreatic sphincterotomy, persistent standard cannulation technique) for difficult biliary cannulation with each other were identified. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. Pairwise and network meta-analysis and ranking according to surface under the cumulative ranking curve(SUCRA) for all methods were performed. Results Eighteen RCTs were identified according to selection criteria, and 2 033 patients were enrolled. The use of transpancreatic sphincterotomy over persistent standard cannulation technique (RR=1.34, 95% CI: 1.02-1.77) and over pancreatic guidewire-assisted technique（RR=1.26, 95% CI: 1.00-1.60）significantly increased the success rate of biliary cannulation. Based on SUCRA ranking, transpancreatic sphincterotomy followed by early needle-knife techniques were ranked highest in terms of increasing the success rate of biliary cannulation. Only early needle-knife technique significantly decreased PEP rate when compared with persistent standard cannulation technique (RR=0.53, 95％CI: 0.30-0.94), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR=0.41， 95％CI: 0.17-0.99; RR=0.49， 95％CI: 0.25-0.96; respectively). Based on SUCRA ranking, early needle-knife technique followed by transpancreatic sphincterotomy were ranked highest for decreasing the PEP rate of biliary cannulation. Conclusions Transpancreatic sphincterotomy increases the success rate of difficult biliary cannulation in ERCP; early needle-knife technique and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered as a choice of difficult biliary cannulation.

Keywords

• |endoscopic retrograde cholangio-pancreatography|difficult biliary cannulation|network meta-analysis