Background and study aims: Precut papillotomy is considered a risk factor for endoscopic retrograde cholangiopancreatography
(ERCP)-related complications; however whether the complication risk is due to precut
itself or to the prior prolonged attempts is still debated; therefore, early precut
implementation has been suggested to reduce the complication rate. We conducted a
meta-analysis of randomized controlled trials (RCTs) comparing cannulation and complication
rates of early precut implementation with persistent attempts by the standard approach.
Methods: RCTs that compared cannulation and complication rates of the early precut implementation
and of persistent attempts by the standard approach were included. Summary effect
sizes were estimated by odds ratio (OR) with a random-effects model and by Peto OR.
Results: Six RCTs with a total of 966 subjects met the inclusion criteria. Overall cannulation
rates were 90 % in both randomization groups (OR 1.20; 95 % confidence interval [CI]
0.54 – 2.69). Post-ERCP pancreatitis developed in 2.5 % of patients randomized to
the early precut groups and in 5.3 % of patients from the persistent attempts groups
(OR 0.47; 95 %CI 0.24 – 0.91). The overall complication rates, considering pancreatitis,
bleeding, cholangitis, and perforation rates, were 5.0 % in the early precut groups
and 6.3 % in the persistent attempts groups (OR 0.78; 95 %CI 0.44 – 1.37).
Conclusions: RCTs that investigated the issue of timing of the precut procedure were limited.
Current evidence suggests that in experienced hands the early implementation of precut
and persistent cannulation attempts have similar overall cannulation rates; early
precut implementation reduces post-ERCP pancreatitis risk but not the overall complication
rate. Further studies are needed to confirm these findings.
References
Meta-analysis. In: Rothman KJ GS, ed Modern Epidemiology. 2nd ed. Philadelphia; Lippincot-Raven
1998: 643-673 http://Available from www.cochrane-handbook.org
franco.bazzoli@unibo.it
