Does early ERCP ± ES reduce the morbidity and mortality of acute gallstone pancreatitis? A meta-analysis

Abstract

There are conflicting reports concerning the benefits of early endoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) in patients with acute gallstone pancreatitis (AGP). The issue of whether or not to perform early ERCP ± ES is of clinical importance because AGP is associated with significant morbidity and mortality. Aim: To determine if early ERCP with or without ES reduces the morbidity and mortality of patients with AGP. Methods: Using MEDLINE and manual searches, we identified four randomized controlled trials that compared the use of early ERCP ± ES to conservative therapy in patients with pancreatitis. We contacted authors to provide data of patients with AGP and stratified the results based on the severity of pancreatitis, as determined by the early predictors. We used odds ratios (ORs) of the morbidity and mortality, and the Mantel-Haenszel method. Results: Of the 838 patients included in the four studies performed in four countries - 695 patients had AGP and were randomized to early ERCP ± ES versus conservative therapy. The common OR estimators showed that early ERCP ± ES reduced the morbidity and mortality of patients with AGP versus conservative treatment, especially in patients who were predicted to have severe pancreatitis. Prognosis Outcomes Odds Ratio (95% CI) Mild Morbidity 0.66(0.42- 1.03) Mild Mortality 0.60(0.16- 2.30) Severe Morbidity 0.27(0.15- 0.48) Severe Mortality 0.37(0.16- 0.85) All grades Morbidity 0.51 (0.36- 0.70) All grades Mortality 0.44 (0.23-0.87)*Lower OR favors use of early ERCP ± ES.*Heterogeneity was present. Conclusion: Early ERCP with or without ES reduces the morbidity and mortality of patients with AGP, especially in patients who were predicted, by the early prognostic indices, to have severe pancreatitis.