Purpose: Considerable controversy remains about the usefulness of the different electrocautery techniques for the prevention of PEP. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the association between the types of current used for EBS and PEP.
Methods: We performed a search in MEDLINE, EMBASE, CENTRAL, CINAHL up to October 2011 with no language restriction. Conference proceedings from DDW and UEGW in the past 8 years were hand-searched. RCTs that compared the different types of current for EBS and reported data for PEP were included. Study selection, data extraction and methodological quality assessment using the risk of bias instrument were conducted independently by two authors. Primary outcome was incidence of PEP. Secondary outcomes included severity of PEP, post-EBS bleeding, bleeding during EBS, post-EBS cholangitis, perforation, and mortality. Revman 5.1 was used to calculate pooled risk ratios (RR) with 95% confidence intervals (Mandel-Haenszel method; random effects model). Heterogeneity was assessed by Chi2 test (P<0.15) and I2 test (>25%). For overall pooled results on the incidence of PEP, sensitivity analyses included intention-to-treat vs. per-protocol analyses and random- vs. fixed-effect models. To explore possible sources of heterogeneity, a priori subgroup analysis were conducted on risk of bias, publication type, and pre-cut sphincterotomy. Publication bias was assessed using funnel plots.
Results: Eleven RCTs (2026 participants) met the inclusion criteria. Seven types of comparisons were identified, but meta-analyses were only possible for: 1) pure cut vs. blended, 2) pure cut vs. sequential (first cut then blended), 3) pure cut vs. Endocut, and 4) blended vs. Endocut. No significant difference in the rate of PEP was found between any of the comparisons, although there was a trend favoring pure cut current (Table). Compared to blended, sequential and Endocut separately or in combination, pure cut was associated with an increased risk of bleeding during EBS, but most episodes (93%) were mild and did not require any interventions. There were insufficient data to analyze cholangitis, perforation and mortality. The results were robust to sensitivity analyses. However, there was significant heterogeneity among studies, which could not be explained by subgroup analyses.
Conclusion: Based on limited available evidence, the role of electrosurgical current for EBS in the prevention of PEP remains uncertain, and more RCTs are required. As Endocut is increasingly being used for EBS, future research should evaluate its safety and efficacy compared to pure cut current.