Home > DARE Reviews > Does endoscopic retrograde...

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Does endoscopic retrograde cholangiopancreatography reduce the risk of local pancreatic complications in acute pancreatitis? A systematic review and metaanalysis

MS Petrov, AF Uchugina, and MV Kukosh.

Review published: 2008.

CRD summary

This review concluded that the early use of endoscopic retrograde cholangiopancreatography in patients with acute pancreatitis did not significantly reduce pancreatic complications compared with conservative treatment, regardless of pancreatitis severity. The authors' conclusions should be interpreted cautiously given the small sample sizes, some concerns about the quality of included trials and uncertainties surrounding aspects of the review process.

Authors' objectives

To determine the effect of early endoscopic retrograde cholangiopancreatography (ERCP - radiographic examination of the bile ducts and pancreas) compared with conservative treatment in the management of patients with acute biliary pancreatitis.

Searching

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Science Citation Index were searched from 1981 to December 2007 with no language restrictions. Search terms were reported. Proceedings of major gastroenterology conferences were searched to December 2007. References of retrieved studies were also checked.

Study selection

Randomised controlled trials (RCTs) that compared endoscopic retrograde cholangiopancreatography (ERCP), with or without endoscopic sphincterotomy) versus conservative treatment in patients with acute pancreatitis were eligible for inclusion. Patients were required to receive ERCP within 72 hours of admission.

The review outcomes were local pancreatic complications including infected pancreatic necrosis, pancreatic abscess, and pancreatic pseudocyst (according to the Atlanta Classification). Also assessed were the incidence of bile stone detection and procedure-related complications.

Included trials initiated early ERCP from within 24 to within 72 hours after admission or onset of disease. Severity of disease was defined using the Glasgow, Hong Kong, Acosta or APACHE II criteria; most trials included both patients with mild and severe pancreatitis.

The authors did not state how the papers were selected for the review.

Assessment of study quality

The trials were assessed for validity using the criteria of randomisation, allocation concealment, blinding, evaluation of losses to follow-up, and selective reporting of outcomes.

The authors did not state how many reviewers performed the validity assessment.

Data extraction

Data on numbers of events were extracted to permit the calculation of relative risks (RR) with 95% confidence intervals (CI) for each outcome. The numbers of attempted and successful procedures, and the need for endoscopic sphincterotomy were also extracted. Authors were contacted for additional data where necessary.

Two reviewers independently extracted the data using a standardised form, with discrepancies resolved through discussions with all reviewers.

Methods of synthesis

Pooled relative risks with 95% confidence intervals were calculated using DerSimonian and Laird random-effects model met-analyses. Statistical heterogeneity between trials was assessed using the Χ2 and I2 statistics.

Subgroup analyses of patients with mild acute pancreatitis and those with severe acute pancreatitis were conducted.

Publication bias was assessed through visual inspection of funnel plots.

Results of the review

Five RCTs were included in the review (n=717 patients). Sample size ranged from 61 to 238 patients. All trials showed complete outcome reporting. Three trials reported losses to follow-up. Only two trials reported appropriate methods of randomisation and allocation concealment. None of the trials were blinded.

There was no statistically significant difference in the incidence of pancreatic complications with early endoscopic retrograde cholangiopancreatography (ERCP) compared with conservative management (RR 0.94, 95% CI 0.63 to 1.40; five RCTs, I2=0%).

Subgroup analyses of patients with mild versus severe acute pancreatitis showed similar results. ERCP was successful for 93% of patients in early intervention groups and 92% of patients in conservative treatment groups. Bile duct stones were visualised in 46% of procedures in the early ERCP groups and in 39% of procedures in the conservative treatment groups. An overall rate of procedure related mortality of 0.8% and a 2.9% complication rate was reported.

There was no evidence of publication bias.

Authors' conclusions

The early use of endoscopic retrograde cholangiopancreatography did not result in a significantly reduced risk of local pancreatic complications for patients with either mild or severe acute pancreatitis.

CRD commentary

The review question and the inclusion criteria were clear. The authors searched three relevant databases, as well as other sources, with no language restrictions, reducing the chance that relevant studies were omitted or selection bias introduced. Publication bias was assessed, but the analysis was unlikely to be informative with so few included trials. The authors reported using methods designed to reduce reviewer bias and error in the extraction of data, but not at other stages of the review process.

The assessment of trial quality used appropriate criteria, but was not used to inform the synthesis although trial quality was variable. The decision to combine the trials using meta-analysis was reasonable; heterogeneity was assessed.

The authors' conclusions reflected the results of the review, but should be interpreted cautiously given the small sample sizes, some concerns about the quality of included trials and uncertainties surrounding aspects of the review process.

Implications of the review for practice and research

Practice: The authors stated that endoscopic retrograde cholangiopancreatography (ERCP) may not be necessary in the evaluation of patients with acute biliary pancreatitis, even when the form of the disease is severe. They also stated that diagnostic ERCP should be replaced by methods such as endoscopic ultrasonography.

Research: The authors did not state any implications for further research.

Funding

Not stated.

Bibliographic details

Petrov MS, Uchugina AF, Kukosh MV. Does endoscopic retrograde cholangiopancreatography reduce the risk of local pancreatic complications in acute pancreatitis? A systematic review and metaanalysis Surgical Endoscopy 2008; 22(11): 2338-2343. [PubMed: 18528624]

Other publications of related interest

Petrov MS, van Santvoort HC, Besselink MG, van der Heijden GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Annals of Surgery 2008;247(2):250-257.

Indexing Status

Subject indexing assigned by NLM

MeSH

Cholangiopancreatography, Endoscopic Retrograde; Humans; Pancreatitis /complications /radiography /surgery; Postoperative Complications /prevention & control; Randomized Controlled Trials as Topic; Risk

AccessionNumber

12009101285

Database entry date

23/02/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18528624

PubMed Health Blog...

read all...

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...