Aggressive hydration plus Nonsteroidal Anti-Inflammatory Drugs versus Nonsteroidal Anti-Inflammatory Drugs alone for preventing post-ERCP pancreatitis: a meta-analysis

BACKGROUND & AIMS: Post-ERCP pancreatitis (PEP) remains the most frequent adverse event after ERCP. Although rectal NSAIDs and aggressive intravenous hydration are guideline-endorsed, the incremental benefit of adding hydration to NSAIDs is uncertain. We performed a meta-analysis of randomized controlled trials (RCTs) comparing NSAIDs plus aggressive hydration versus NSAIDs alone for PEP prevention. METHODS: A systematic search in MEDLINE, Scopus, and Cochrane Library databases was performed for RCTs comparing NSAIDs plus aggressive hydration versus NSAIDs alone in adults undergoing ERCP. For the primary outcome a random-effects meta-analysis was conducted to estimate the PEP pooled risk ratios (RRs) with 95% CIs. Supplementary analyses included pooled arm-specific PEP incidence, sensitivity analyses for few trials and sparse events, and trial sequential analysis (TSA). RESULTS: Eight RCTs with a total of 1,903 patients were included. The pooled arm-specific incidence of PEP was 2.8% (95% CI 0.4%-6.7%) with NSAIDs plus aggressive hydration and 7.6% (95% CI 5.2%-10.4%) with NSAIDs alone.. The DerSimonian-Laird random-effects analysis suggested a directionally favorable but statistically inconclusive estimate with combination prophylaxis (RR 0.66, 95% CI 0.40-1.08; I²=18%),whereas the pooled risk difference was -3.8% (95% CI -6.3 to -1.4). . The REML/Hartung-Knapp analysis was also inconclusive (RR 0.73, 95% CI 0.45-1.18). Trial sequential analysis showed that the required information size (RIS) had not been reached. CONCLUSIONS: Compared with NSAIDs alone, the addition of aggressive hydration resulted in a directionally lower but statistically inconclusive relative risk of PEP. Although the pooled risk difference favored combination therapy, the small-sample-robust and trial-sequential analyses remained inconclusive. The available evidence therefore does not establish superiority.