2798 Meta-Analysis and Systematic Review of Initial Endoscopic Therapy for Cholangitis

INTRODUCTION: The initial endoscopic treatment of ascending cholangitis is controversial. It has been proposed that management should be limited to decompression alone while the alternative is to additionally perform sphincterotomy and/or stone removal to address the underlying etiology. Our aim was to compare the effectiveness and safety of endoscopic decompression alone to decompression combined with other endotherapy for ascending cholangitis. METHODS: We systematically searched Embase, Medline, the Cochrane Library, and ClinicalTrials.gov from inception to April 22, 2019. Studies were screened by two independent reviewers using Covidence software and standardized extraction forms. We included trials that compared endoscopic decompression and decompression combined with other endotherapy. Our primary outcome was the odds of effective decompression by decompression alone versus combined with other endotherapy. Our secondary outcome was the odds of adverse events (post ERCP pancreatitis, hemorrhage, mortality). Pooled odds ratios and proportions were estimated using the random effects model for the two approaches. RESULTS: 10,508 abstracts and 256 full text documents were reviewed. Six comparative reports of decompression alone versus decompression with other endotherapy were included in the meta-analysis. These studies capture the results for 462 patients; 205 underwent endoscopic (stent or nasobiliary) decompression alone and 257 decompression plus other endotherapy. There was no difference in success of cholangitis therapy for decompression combined with sphincterotomy and other therapeutic maneuvers as opposed to decompression alone (OR 1.3 [95% CI 0.3-5.6]); there was also no difference in mortality (OR 0.4 [0.4-7.3]). There were more adverse events for decompression combined with sphincterotomy and other maneuvers (OR 2.5 [1.0-6.5]) driven by a higher rate of bleeding (OR 9.1 [2.4-34.7])(Figure 1); there was no difference in rates of post ERCP pancreatitis (OR 0.7 [0.2-2.1]). CONCLUSION: In cholangitic patients, the addition of therapeutic maneuvers including sphincterotomy to biliary decompression is associated with higher rates of adverse events and particularly bleeding compared to decompression alone. Nevertheless, the included studies did not account for adverse events during subsequent ERCP to remove biliary stones in those initially managed with decompression alone. In cholangitic patients who are coagulopathic or would not tolerate adverse events, decompression alone should be considered.