Rectal Nonsteroidal Anti-inflammatory Drugs, Aggressive Hydration with Lactated Ringer’s Solution, Somatostatin or Combinations for Prophylaxis Post ERCP Acute Pancreatitis: A Network Meta-analysis

AIM: To evaluate the clinical efficacy of Rectal nonsteroidal anti-inflammatory drugs (NSAIDs), Aggressive hydration with Lactated Ringer's solution (ALRS), somatostatin or combinations in preventing pancreatitis and hyperamylasemia after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A systematic review was conducted following PRISMA guidelines, searching all studies from the PubMed, Embase, Ovid, Cochrane library and Google Scholar. Stata software 14.0 and Rev Man 5.4 were used for statistical analysis. Outcomes assessed included the incidence of post-ERCP pancreatitis (PEP), post ERCP hyperamylasemia (PEHA), bleeding and perforation. RESULTS: Forty-one trials were identified and included in the network meta-analysis, involving 15627 patients. Somatostatin (OR=0.49, 95%CI= 0.34 to 0.71), rectal indomethacin (OR=0.63, 95%CI= 0.44 to 0.9) and rectal indomethacin + somatostatin (OR=0.31, 95%CI= 0.14 to 0.69) were all more efficacious than placebo in preventing PEP. The combination of rectal indomethacin and somatostatin was the best preventive strategy for PEP, with a surface under the cumulative ranking curves (SUCRA) probability of 80.9%. In terms of PEHA, somatostatin (OR=0.18, 95%CI= 0.1 to 0.33), rectal indomethacin (OR=0.68, 95%CI= 0.55 to 0.84), and rectal indomethacin + somatostatin (OR=0.45, 95%CI= 0.28 to 0.73) were all more efficacious than placebo in preventing PEHA. Based on the SUCRA, rectal indomethacin + somatostatin (100%) was found to be the most efficacious modality for the prevention of PEHA. In addition, rectal indomethacin + somatostatin showed the lowest risk of bleeding (77.5%) and perforation (93.8%). CONCLUSION: The combination of rectal indomethacin and somatostatin was most effective for preventing PEP and PEHA, which has the lowest risk of bleeding and perforation. Given the limited number of studies directly assessing this combination, SUCRA rankings do not always imply clinically meaningful superiority, more large-scale clinical RCTs need to be included in the future to confirm this conclusion.