P2747 - Comparative Efficacy of Different Methods for Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: A Systematic Review and Network Meta-Analysis

Daryl Ramai, MD, MSc¹, Antonio Facciorusso, MD, PhD², Paraskevas Gkolfakis, ³, Shahab R. Khan, MBBS⁴, Ioannis S. Papanikolaou, MD, PhD⁵, Konstantinos Triantafyllou, MD⁵, Alberto Tringali, MD⁶, Douglas Adler, MD^7
1University of Utah, Salt Lake City, UT; ²University of Foggia, Foggia, Puglia, Italy; ³Erasme University Hospital, Brussels, Brussels Hoofdstedelijk Gewest, Belgium; ⁴Brigham & Women's Hospital, Harvard Medical School, Boston, MA; ⁵Attikon University General Hospital, Athens, Attiki, Greece; ⁶Conegliano Hospital, Conegliano, Lombardia, Italy; ⁷Center for Advanced Therapeutic Endoscopy, Salt Lake City, UT

Introduction: Several methods with variable efficacy have been proposed for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). We assessed the comparative efficacy of different strategies for difficult biliary cannulation, through a network meta-analysis combining direct and indirect treatment comparisons.

Methods: We identified 17 randomized controlled trials (RCTs) (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence.

Results: Low quality evidence supports the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (Risk ratio [RR] 1.29, 1.05-1.59) and over any other adjunctive intervention (RR 1.21, 1.01-1.44 vs. pancreatic guidewire-assisted technique, RR 1.19, 1.01-1.43 vs. early needle knife techniques, and RR 1.47, 1.03-2.10 vs. pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any of the other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score 0.97) followed by early needle knife techniques (P-score 0.62) were ranked highest in terms of increasing success rate of biliary cannulation. Early needle knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR 0.61, 0.37-1.00), whereas both early needle knife techniques and transpancreatic sphincterotomy led to lower PEP rate as compared with pancreatic guidewire-assisted technique (RR 0.49, 0.23-0.99 and RR 0.53, 0.30-0.92, respectively).

Discussion: Transpancreatic sphincterotomy increases success rate of biliary cannulation as compared to persistence with the standard cannulation techniques. Early needle knife techniques and transpancreatic sphincterotomy are superior to the other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation


Figure: Forest plots reporting estimates derived from network meta-analysis assessing success rate of biliary cannulation.

	Success rate of biliary cannulation		Post-ERCP pancreatitis rate
	Risk Ratio (95% CI)	Quality of Evidence	Risk Ratio (95% CI)	Quality of Evidence
All adjunctive treatments vs. Persistence with standard cannulation techniques
Pancreatic guidewire-assisted technique	1.07 (0.87-1.31)	Low	1.24 (0.60-2.56)	Very low
Early needle knife techniques	1.08 (0.95-1.23)	Low	0.61 (0.37-1.00)	Low
Late needle knife techniques	0.96 (0.67-1.37)	Low	--	--
Pancreatic stent-assisted technique	0.88 (0.60-1.27)	Low	2.32 (0.35-15.34)	Very low
Transpancreatic sphincterotomy	1.29 (1.05-1.59)	Low	0.66 (0.29-1.47)	Low
vs. Pancreatic guidewire-assisted technique
Early needle knife techniques	1.01 (0.83-1.23)	Low	0.49 (0.23-0.99)	Low
Late needle knife techniques	0.89 (0.61-1.31)	Low	--	--
Pancreatic stent-assisted technique	0.82 (0.60-1.12)	Low	1.85 (0.32-10.65)	Very low
Transpancreatic sphincterotomy	1.21 (1.01-1.44)	Low	0.53 (0.30-0.92)	Low
vs. Early needle knife techniques
Late needle knife techniques	0.88 (0.63-1.23)	Low	--	--
Pancreatic stent-assisted technique	0.81 (0.56-1.17)	Low	3.78 (0.57-25.12)	Very low
Transpancreatic sphincterotomy	1.19 (1.01-1.43)	Low	1.08 (0.50-2.33)	Very low
Vs Late needle knife techniques
Pancreatic stent-assisted technique	0.91 (0.55 -1.50)	Low	--	--
Transpancreatic sphincterotomy	1.34 (0.92-1.96)	Low	--	--
Vs Pancreatic stent-assisted technique
Transpancreatic sphincterotomy	1.47 (1.03-2.10)	Low	0.28 (0.04-1.78)	Low

Table: GRADE Summary of Findings reporting the comparative efficacy of different methods for biliary difficult cannulation. Quality of the evidence was rated based on GRADE methodology. RCTs of direct comparison were rated down for presence of any of the following factors – risk of bias in literature, inconsistency, indirectness, imprecision and publication bias. Quality of indirect estimates was initially derived from the lowest quality of first-order loops for direct estimates contributing to the indirect estimates. Quality of the network meta-analysis was derived from quality of combination of direct and indirect estimates and transitivity of trials. Risk ratios reaching the significance threshold are reported in bold.


Disclosures:
Daryl Ramai indicated no relevant financial relationships.
Antonio Facciorusso indicated no relevant financial relationships.
Paraskevas Gkolfakis indicated no relevant financial relationships.
Shahab Khan indicated no relevant financial relationships.
Ioannis Papanikolaou indicated no relevant financial relationships.
Konstantinos Triantafyllou indicated no relevant financial relationships.
Alberto Tringali indicated no relevant financial relationships.
Douglas Adler indicated no relevant financial relationships.


Daryl Ramai, MD, MSc¹, Antonio Facciorusso, MD, PhD², Paraskevas Gkolfakis, ³, Shahab R. Khan, MBBS⁴, Ioannis S. Papanikolaou, MD, PhD⁵, Konstantinos Triantafyllou, MD⁵, Alberto Tringali, MD⁶, Douglas Adler, MD⁷. P2747 - Comparative Efficacy of Different Methods for Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: A Systematic Review and Network Meta-Analysis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.