Systematic Reviews
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Nov 16, 2020; 12(11): 469-487
Published online Nov 16, 2020. doi: 10.4253/wjge.v12.i11.469
Nonsteroidal anti-inflammatory drug effectivity in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis
Juan Pablo Román Serrano, José Jukemura, Samuel Galante Romanini, Paúl Fernando Guamán Aguilar, Juliana Silveira Lima de Castro, Isabela Trindade Torres, José Andres Sanchez Pulla, Otavio Micelli Neto, Eloy Taglieri, José Celso Ardengh
Juan Pablo Román Serrano, José Jukemura, José Celso Ardengh, Department of Gastroenterology, University of Sao Paulo, São Paulo 05403-000, São Paulo, Brazil
Samuel Galante Romanini, Juliana Silveira Lima de Castro, Isabela Trindade Torres, Otavio Micelli Neto, Eloy Taglieri, José Celso Ardengh, Department of Gastrointestinal Endoscopy Service, Hospital 9 de Julho, São Paulo 01409002, São Paulo, Brazil
Paúl Fernando Guamán Aguilar, Department of Gastroinestinal, Catholic University of Cuenca, Cuenca 010101, Ecuador
José Andres Sanchez Pulla, Department of General Surgery, Servidor Municipal Hospital, São Paulo 01532-001, Brazil
Author contributions:  Serrano JPR, Ardengh JC and Jukemura J carried out the analysis and drafted the initial paper; Serrano JPR, Guaman PF and Sanchez JA contributed to the review changes and language; Romanini SG, de Castro JSL, Torres IT, Micelli O and Taglieri E contributed with data collection; all authors reviewed and approved the final paper as submitted.
Conflict-of-interest statement: The authors deny any conflict of interest
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Juan Pablo Román Serrano, MD, Academic Fellow, Department of Gastroenterology, University of São Paulo, Rua Dr. Eneas de Carvalho, São Paulo 05403-000, São Paulo, Brazil. hcjprs2412@hotmail.com
Received: April 20, 2020
Peer-review started: April 20, 2020
First decision: June 15, 2020
Revised: June 24, 2020
Accepted: September 18, 2020
Article in press: September 18, 2020
Published online: November 16, 2020
Processing time: 210 Days and 1.2 Hours
Abstract
BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct. Although the therapeutic success rate of ERCP is high, the procedure can cause complications, such as acute pancreatitis [post-ERCP pancreatitis (PEP)], bleeding and perforation.

AIM

To assess the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in preventing PEP during follow-up.

METHODS

Databases such as MEDLINE, EMBASE and Cochrane Central Library were searched. Only randomized controlled trials (RCTs) comparing the efficacy of NSAIDs and placebo for the prevention of PEP were included. Outcomes evaluated included the incidence of PEP, severity of pancreatitis, route of administration, types, dose, and timing of administration of NSAIDs.

RESULTS

Twenty-six RCTs were considered eligible with a total of 8143 patients analyzed. Overall, 4020 patients used NSAIDs before ERCP and 4123 did not use NSAIDs (control group). Ultimately, 298 cases of post-ERCP acute pancreatitis were diagnosed in the NSAID group and 484 cases in the placebo group. The risk of PEP was lower in the NSAID group risk difference (RD): -0.04; 95% confidence interval (CI): -0.07 to - 0.03; number needed to treat (NNT), 25; P < 0.05. NSAID use effectively prevented mild pancreatitis compared to placebo use (2.5% vs 4.1%; 95%CI: -0.05 to -0.01; NNT, 33; P < 0.05), but information on moderate PEP and severe PEP could not be fully elucidated. Only rectal administration reduced the incidence of PEP with RD: -0.06; 95%CI: -0.08 to -0.04; NNT, 17; P < 0.05). Furthermore, only the use of diclofenac or indomethacin was effective in preventing PEP, at a dose of 100 mg, which must be administered before performing ERCP.

CONCLUSION

Rectal administration of diclofenac and indomethacin significantly reduced the risk of developing mild PEP. Additional RCTs are needed to compare the efficacy between NSAID routes of administration in preventing PEP.

Keywords: Pancreatitis; Endoscopic retrograde cholangiopancreatography; Diclofenac; Indomethacin; Rectal

Core Tip: The present systematic review and meta-analysis shows that the use of non-steroidal anti-inflammatory drugs reduced the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). This review is the first to be carried out in Latin America with a large number of randomized controlled trials. The present study shows that rectal administration of diclofenac and indomethacin before endoscopic retrograde cholangiopancreatography can reduce the incidence of mild PEP in high, medium and low risk patients.