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Evidence summaries

Early Routine Endoscopic Retrograde Cholangiopancreatography Strategy Versus Early Conservative Management Strategy in Acute Gallstone Pancreatitis

In patients with acute gallstone pancreatitis and co-existing cholangitis or biliary obstruction, early ERCP appears to reduce mortality and local or systemic complications. There may be no benefit in early routine ERCP for all patients Level of evidence: "B"

The quality of evidence is downgraded by study limitations (unclear allocation concealment).

Summary

A Cochrane review [Abstract] 1 included 5 studies with a total of 644 patients assessing the clinical effectiveness and safety of the early routine endoscopic retrograde cholangiopancreatography (ERCP) strategy compared to the early conservative management with or without selective use of ERCP strategy.

OutcomeNumber of participants (studies)Assumed risk(Early conservative management +/- delayed or selective ERCP)Corresponding risk (Early routine ERCP)Relative effect (95% CI)
All-cause mortalityITT-analysis644 (5)60 per 100044 per 1000(11 to 181)RR 0.74 (0.18 to 3.03)
Local complications*(necrosis, abscess, pseudocyst)517 (4)149 per 1000128 per 1000(77 to 213)RR 0.86(0.52 to 1.43)
Systemic complications*405 (4)150 per 100089 per 1000(47 to 167)RR 0.59(0.31 to 1.11)
*defined by the Atlanta Classification
There were no statistically significant differences between the two strategies in local and systemic complications as defined by authors of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76, 95% CI 0.53 to 1.09 respectively).

Among trials that included patients with cholangitis, the early routine ERCP strategy significantly reduced mortality (RR 0.20, 95% CI 0.06 to 0.68, n = 415; 5 studies), local and systemic complications as defined by the Atlanta Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR 0.37, 95% CI 0.18 to 0.78 respectively) and by authors of the primary study (RR 0.50, 95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21 to 0.82 respectively).

Among trials that included patients with biliary obstruction, the early routine ERCP strategy was associated with a reduction in local complications (RR 0.54, 95% CI 0.32 to 0.91), and a trend towards reduction of local and systemic complications as defined by the Atlanta Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR 0.56, 95% CI 0.30 to 1.02 respectively).

Clinical comments

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