| Objective:The success rate of Endoscopic retrograde cholangiopancreatography (ERCP)and its effects on the incidence of post-ERCP pancreatitis(PEP)were compared by means of Meta analysis,in order to provide evidence for Endoscopic Endoscopic retrograde cholangiopancreatography(ERCP)in the selection of strategies for difficult bile duct intubation.Methods:Various Chinese and English literature databases,including Pub Med,Embase,The Cochrane Library,CNKI,VIP,Wanfang,etc.,were searched by computer to find relevant literature on coping strategies for ERCP difficult biliary intubation.The retrieval was conducted by combining subject words with free words,and the retrieval time was from the establishment of the database to September 2020.After the inclusion and exclusion criteria were established,two researchers independently screened and extracted the literature.The literature evaluation used Minors evaluation entries to analyze the quality of the included literatures.Data were analyzed using Rev Man 5.3 software.Heterogeneity was first tested,and effect models were selected according to the heterogeneity results for analysis.Finally,Odds ratio(OR)and 95%Confidence intervals(CI)were used to describe the final results.Results:According to the inclusion and exclusion criteria,48 articles were included,with a total of 6,392 subjects.There are three literatures comparing the single-guidewire technique(SGT)with the double-guidewire technique(DGT).Four studies compared DGT with wire guide cannular-pancreatic stent(WGC-PS).Comparison of DGT and transpancreatic sphincterotomy(TPS)was performed in 23 studies.There were 20 literatures comparing TPS with needle knife papillotomy(NKP).The correlation between NKP and precut sphincterotomy(PST)was studied in 7 articles.There were 5 studies comparing NKP with needle-knife fistulotomy(NKF).Results of Meta-analysis showed that there were 3comparative studies based on SGT and DGT.Heterogeneity analysis showed that I~2=68%in terms of success rate,P=0.04,indicating high heterogeneity,and random effect model was adopted.As for the incidence of PEP,I~2=18%,P=0.30,with low heterogeneity,fixed effect model was adopted.The results showed that DGT intubation success rate was higher than SGT,and the incidence of PEP was lower,the difference was statistically significant(success rate OR=0.46,95%CI 0.20-1.09;PEP incidence OR=1.10,95%CI 0.67-1.79).There were 4 comparative studies involving DGT and WGC-PS.Heterogeneity analysis showed that I~2=81%in terms of success rate,P=0.001,indicating high heterogeneity.Random-effect model was adopted.As for the incidence of PEP,I~2=0%,P=0.70,the heterogeneity was low,and fixed effect model was adopted.The results showed that the intubation success rate of DGT was higher than that of WGC-PS,but the incidence of PEP in DGT was higher than that of WGC-PS,and the difference was statistically significant(OR=1.57,95%CI0.42-5.84;PEP incidence OR=1.87,95%CI 0.81-3.92).There were 23comparative studies involving DGT and TPS.Heterogeneity analysis showed that I~2=54%in terms of success rate,P=0.001,indicating high heterogeneity.The random-effect model was adopted.As for the incidence of PEP,I~2=31%,P=0.08,with low heterogeneity,fixed effect model was adopted.The results showed that the intubation success rate of TPS was higher than that of DGT,but the incidence of PEP in TPS was higher than that of DGT,and the difference was statistically significant(OR=0.59,95%CI 0.40-0.87;PEP incidence OR=0.88,95%CI 0.64-1.22).There were 20 comparative studies involving TPS and NKP.Heterogeneity analysis showed that the literature heterogeneity in terms of success rate and PEP incidence was low,and a fixed-effect model could be used(success rate I~2=42%,P=0.03;PEP incidence I~2=0%,P=0.76).The results showed that the intubation success rate of NKP was higher than that of TPS,but the incidence of PEP in NKP was higher than that of TPS,and the difference was statistically significant(OR=0.88,95%CI 0.66-1.18;PEP incidence OR=0.75,95%CI 0.52-1.09).There were 7 comparative studies involving NKP and PST.Heterogeneity analysis showed that I~2=63%in terms of success rate,P=0.01.The heterogeneity of literatures was high,and a random-effect model was adopted.As for the incidence of PEP,I~2=0%,P=0.93,the literature had low heterogeneity,and a fixed-effect model could be used.The results showed that the intubation success rate of NKP was higher than that of PST,and the incidence of PEP in NKP was lower than that of PST,the difference was statistically significant(OR=2.22,95%CI1.00-4.92;PEP incidence OR=0.79,95%CI 0.38-1.63).There were 5comparative studies involving NKP and NKF.Heterogeneity analysis showed that I~2=65%in terms of success rate,P=0.02.The heterogeneity of literatures was high,and a random-effect model was adopted.As for the incidence of PEP,I~2=0%,P=0.59,the literature had low heterogeneity,and a fixed-effect model could be used.The results showed that the intubation success rate of NKF was higher than that of NKP,and the incidence of PEP in NKF was lower than that of NKP,the difference was statistically significant(success rate OR=0.92,95%CI 0.84-1.00;PEP incidence OR=2.42,95%CI 1.10-5.30).Conclusion:All ERCP methods to assist difficult bile duct intubation can achieve a high success rate,among which NKF has the highest success rate and PEP has the lowest incidence.It seems that NKF is the optimal solution,but the other methods also have their own advantages.If the guide wire repeatedly enters the pancreatic duct during ERCP biliary intubation,DGT or WGC-PS(DGT is preferred)may be the first option.If this is not successful,TPS may be tried.The above methods can be tried by most endoscopists,but experienced operators will have a higher success rate.If it is still unsuccessful,PST,NKP and NKF are feasible,among which NKF is the first choice,and it needs to be operated by experienced endoscopic physicians.If it is not successful,a second ERCP should be considered and the operation should be carried out after the elimination of duodenal papillary edema.If the second ERCP is still unsuccessful,endoscopic ultrasound-guided biliary drainage(EUS-BD)or percutaneous transhepatic cholangial drainage(PTCD),or even surgery,may be considered. |
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