Skip the supp before the ERCP: an analysis of 6174 ERCPs over twenty years

Introduction

International guidelines (1) recommend routine NSAID prophylaxis as ‘Level 1A’ evidence for the prevention of post-ERCP pancreatitis. The aim of this study was to evaluate the effect of this routine in an unselected population in a high-volume biliary surgery center over two decades, with a particular focus on how the implementation of guidelines affects outcomes. The unit routinely introduced Diclofenac 100mg sup prior to ERCP in 2016.

A recently published meta-analysis has questioned the value of NSAIDs as prophylaxis against post-ERCP pancreatitis (2) and previous meta-analysis has pointed to NSAIDs as a triggering risk factor for pancreatitis (3).

Methods

6174 consecutive ERCP procedures with 201 outcomes (2006–2025) with clinic-own quality data from gallriks. Analysis: Multivariable logistic regression. The model adjusts for age, sex, malignancy as an indication for ERCP, surgery time, elective status, previous papillotomy, deep cannulation of pancreatic duct, rendezvous technique, and NSAIDs.

Result

Variable Odds Ratio (OR) 95% Conf.int. P-value NSAID (preop) 1,709 1,210–2,414 0.002 Elective procedure 1,375 1,024–1,848 0.034 Operation time (min) 1,013 1,007–1,019 <0.001 Age 0,988 0,979–0,996 0.004 Previous papillotomy 0,223 0,105–0,475 <0.001 Rendez-vous 0,658 0,477–0,906 0.010

Discussion

The results raise doubts about the international expert groups' evaluation of data in the formulation of guidelines. In a time of guideline-driven care, it may be wise to maintain a healthy skepticism. Variation in care is not always undesirable as it means opportunities to let the tree of knowledge grow where the light is strongest.