ORIGINAL ARTICLE
The Effect of Indomethacin in the Prevention of PostYEndoscopic Retrograde Cholangiopancreatography Pancreatitis A Meta-Analysis Dina Ahmad, MD,* Kristi T. Lopez, MD,* Mohammad A. Esmadi, MD,* Gabor Oroszi, MD,Þ Michelle L. Matteson-Kome, PhD,* Abhishek Choudhary, MD,* and Matthew L. Bechtold, MD, FASGE, FACG*
Objectives: Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). Methods: A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. Results: Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34Y0.71; P G 0.01), mild PEP (OR, 0.52; 95% CI, 0.32Y0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24Y0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. Conclusions: Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP. Key Words: indomethacin, pancreatitis, ERCP, meta-analysis (Pancreas 2014;43: 338Y342)
A
cute pancreatitis continues to be the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP).1,2 The reported incidence of post-ERCP pancreatitis (PEP) varies widely mostly because of multiple factors, including the definition used, patient population, methods performed, and operator expertise.3,4 The outcome of PEP can be devastating. Therefore, numerous mechanical and pharmacological interventions have been evaluated in the prevention of PEP.5Y12 To date, there is no pharmacological prophylaxis in routine use, and pancreatic stent placement remains to be the first From the Departments of *Internal Medicine and †Anatomical Pathology, University of Missouri School of Medicine, Columbia, MO. Received for publication February 10, 2013; accepted August 6, 2013 Reprints: Matthew L. Bechtold, MD, FASGE, FACG, Division of Gastroenterology & Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Dr, Columbia, MO (e
The Effect of Indomethacin in the Prevention of PostYEndoscopic Retrograde Cholangiopancreatography Pancreatitis A Meta-Analysis Dina Ahmad, MD,* Kristi T. Lopez, MD,* Mohammad A. Esmadi, MD,* Gabor Oroszi, MD,Þ Michelle L. Matteson-Kome, PhD,* Abhishek Choudhary, MD,* and Matthew L. Bechtold, MD, FASGE, FACG*
Objectives: Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). Methods: A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. Results: Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34Y0.71; P G 0.01), mild PEP (OR, 0.52; 95% CI, 0.32Y0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24Y0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. Conclusions: Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP. Key Words: indomethacin, pancreatitis, ERCP, meta-analysis (Pancreas 2014;43: 338Y342)
A
cute pancreatitis continues to be the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP).1,2 The reported incidence of post-ERCP pancreatitis (PEP) varies widely mostly because of multiple factors, including the definition used, patient population, methods performed, and operator expertise.3,4 The outcome of PEP can be devastating. Therefore, numerous mechanical and pharmacological interventions have been evaluated in the prevention of PEP.5Y12 To date, there is no pharmacological prophylaxis in routine use, and pancreatic stent placement remains to be the first From the Departments of *Internal Medicine and †Anatomical Pathology, University of Missouri School of Medicine, Columbia, MO. Received for publication February 10, 2013; accepted August 6, 2013 Reprints: Matthew L. Bechtold, MD, FASGE, FACG, Division of Gastroenterology & Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Dr, Columbia, MO (e
