S57 Efficacy and Safety of Double Guidewire vs Transpancreatic Papillotomy in Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for hepatobiliary and pancreatic disorders. Selective cannulation of the common bile duct is a crucial step. Difficult biliary cannulation increases the risk of post-ERCP pancreatitis. In cases of failed standard cannulation, transpancreatic sphincterotomy or double guidewire techniques can be employed. This review and meta-analysis aim to compare the efficacy of transpancreatic sphincterotomy and double guidewire in difficult biliary cannulation, focus on post-ERCP adverse events, particularly pancreatitis, and the success rates of cannulation. Methods: This review involved searching Medline, Embase, Lilacs, Central Cochrane, and Google Scholar for studies comparing double guide wire vs transpancreatic sphincterotomy. Outcomes assessed included pancreatitis, successful biliary cannulation, mean cannulation time, and other adverse events. Results: A total of 463 patients from 5 randomized controlled trials were included. The double guidewire group showed a higher risk of post-ERCP pancreatitis and other adverse events (P = 0.009; RR = 1.81 [1.16, 2.83]; I² = 34%) and (P = 0.03; RR = 2.20 [1.10, 4.39]; I² = 0%), respectively. A significant difference favoring transpancreatic was found for successful cannulation and mild pancreatitis (P = 0.01; RR = 0.85 [0.76, 0.94]; I² = 39%) and (P = 0.01; RR = 2.26 [1.20, 4.28]; I² = 35%), respectively. No significant difference was observed for mean cannulation time or moderate to severe pancreatitis (P = 0.18; SMD = -0.37 [–0.91, 0.17]; I² = 79%) and (P = 0.32; RR = 0.97 [0.93, 1.03]; I² = 0%), respectively. A restricted analysis excluding 2 studies that contained external factors inflating the pancreatitis statistics no longer showed a significant difference (P = 0.61; RR = 1.16 [0.66, 2.04]; I² = 0%). Conclusion: Our results provide the highest evidence level, indicating that transpancreatic sphincterotomy may have higher success rates for cannulation and lower post-ERCP pancreatitis and complication rates.