Comparative Risks of Post-ERCP Pancreatitis in Asymptomatic and Symptomatic Choledocholithiasis Patients: A Systematic Review and Meta-Analysis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for choledocholithiasis but carries significant risks such as post-ERCP pancreatitis (PEP) which can cause significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones (CBDS), the need for ERCP in incidentally found asymptomatic CBDS is more controversial and practice varies at an institutional level. This systematic review and meta-analysis compares post-ERCP complications between asymptomatic and symptomatic choledocholithiasis patients. Methods: We conducted a comprehensive search of PubMed, Embase and Web of Science databases up to April 2023 to find studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was PEP, while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel-Haenszel method within a random-effect model. Results: Our analysis incorporated 6 retrospective studies, totaling 2,178 CBDS patients (392 asymptomatic and 1,786 symptomatic). Asymptomatic CBDS patients exhibited a significantly higher risk of PEP (11.7% vs 4.8%; RR 2.59, 95%CI 1.56-4.31, P=0.0002) (Figure 1A). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the groups (Figure 1B-D respectively. Conclusion: Asymptomatic patients appear to have a higher risk of PEP compared to symptomatic patients, while the risk of other post-ERCP complications appear to be similar between both groups. Interventional endoscopists should thoroughly discuss potential complications (particularly PEP) with asymptomatic patients before performing ERCP, and consider utilizing PEP-prevention measures more liberally in this subgroup of patients. Further randomized controlled trials are needed to validate these findings and investigate the efficacy and safety of ERCP intervention versus watchful waiting in managing asymptomatic CBDS.Figure 1.: Forest plots for post-ERCP complications (A - Post-ERCP pancreatitis, B - post-ERCP cholangitis, C - Post-procedure bleeding, D - Perforation) in asymptomatic and symptomatic choledocholithiasis patients.