No Added Benefit of Papillary Spraying of Epinephrine over Rectal Indomethacin for Prevention of Post-ERCP Pancreatitis -A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background Pancreatitis is the most common adverse event following Endoscopic Retrograde Cholangiopancreatography, despite rectal administration of indomethacin. Spraying of epinephrine on the duodenal papilla has been proposed as an adjunct to rectal indomethacin for reducing post-ERCP Pancreatitis. We performed a meta-analysis of randomized clinical trials for the additional protective effect of spraying of papilla with epinephrine while using rectal indomethacin to reduce post-ERCP Pancreatitis. Methods An electronic database search was conducted in PubMed, Embase, Google scholar and Cochrane for eligible prospective, randomized studies. The primary outcome comparison of incidence of post-ERCP Pancreatitis in the combination (rectal indomethacin+epinephrine spraying of papilla) vs. control (indomethacin alone) groups, Pooled proportions (%) were calculated using random effects model and I2 statistic was used to assess heterogeneity among studies. Results A total of 2243 patients (mean age 57.54 years; 52.2% females) were included from three prospective, randomized studies that met the inclusion criteria and investigated the effect of using a combination of epinephrine spraying with rectal Indomethacin on post-ERCP Pancreatitis. The incidence of post-ERCP Pancreatitis was comparable between the combination and control groups (pooled OR: 1.15, CI: 0.58-2.28, p=0.70). There was no statistically significant difference between the two groups in terms of severity of post-ERCP Pancreatitis, or rates of difficult or failed cannulation, pancreas duct cannulation, biliary stricture, precut sphincterotomy, or balloon sphincteroplasty (P>0.05). Conclusions This systematic review and meta-analysis of more than 2000 patients demonstrates a lack of added benefit for the papillary spraying of epinephrine beyond the use of rectal indomethacin to prevent post-ERCP Pancreatitis.


Chandra S Dasari, Madhav Desai, Simon K Lo, Abhiram Duvvuri, Harsh K Patel, Ramprasad Jegadeesan, Viveksandeep Thoguluva Chandrasekar, Prateek Sharma, Divyanshoo R Kohli

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