Endoscopic Sphincterotomy Prior to Biliary Stenting for Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Sofia Coelho Meine, Gabriel de Oliveira Amaral, Mateus Rech Tedesco et al.
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In 30 seconds
This systematic review and meta-analysis of six randomized controlled trials evaluated endoscopic sphincterotomy (ES) before ERCP-guided biliary stenting in 1215 patients with malignant biliary obstruction. Overall, technical success and risks of post-ERCP pancreatitis (PEP), clinically significant bleeding, perforation, cholangitis, cholecystitis, and stent malfunction were similar with and without ES. In studies with a low prevalence of pancreatic cancer, ES was associated with lower PEP risk (RR 0.23; 95% CI 0.12-0.44); no significant difference was found in studies with a high prevalence (RR 0.85; 95% CI 0.57-1.28).
Key findings
- Across six RCTs involving 1215 patients, technical success and the reported adverse outcomes were similar with versus without ES.
- In studies with a low prevalence of pancreatic cancer, ES was associated with reduced PEP risk (RR 0.23; 95% CI 0.12-0.44).
- In studies with a high prevalence of pancreatic cancer, PEP risk did not differ significantly (RR 0.85; 95% CI 0.57-1.28).
Why it matters
The findings suggest that the relationship between ES and post-ERCP pancreatitis may vary with the underlying mix of malignant obstruction etiologies. The overall similarity in bleeding and other reported outcomes also informs assessment of the procedural trade-offs, while the subgroup results caution against assuming a uniform pancreatitis benefit across patient populations.
What to keep in mind
The PEP findings by pancreatic cancer prevalence come from subgroup analyses across trials, rather than a single overall effect applicable to every etiology.