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Combination of rectal indomethacin and pancreatic duct stenting is superior to indomethacin alone in preventing post-ERCP pancreatitis only in patients undergoing double wire cannulation: a case-control study with propensity score matching.

BACKGROUND AND AIMS
Rectal indomethacin and pancreatic duct (PD) stenting (PDS) are recommended for the prevention of post-ERCP pancreatitis (PEP). However, the effects of the combination of the two methods on preventing PEP are controversial. We hypothesized that some group of difficult patients might benefit from the combination of indomethacin plus PDS (IP) compared with indomethacin alone (IN).


METHODS
Patients with native papilla who underwent ERCP in 8 tertiary hospitals were screened. They were enrolled if the cannulation proved difficult and post-procedure indomethacin was administrated. Propensity score matching (PSM) was used to balance the baseline characteristics between IP and IN groups. The primary outcome was post-ERCP pancreatitis (PEP).


RESULTS
Among 4456 patients with available cannulation-related data, 1889 (42.4%) patients had difficult cannulation and received indomethacin. After PSM, both IP and IN groups included 332 patients. PEP was comparable between the two groups (12.7% vs. 10.2%, p=0.329). By subgroup analysis, the PEP rate was found to be lower in the IP group than in the IN group (7.3% vs. 18.2%, p=0.026) in patients undergoing double-guidewire technique (DGT). The results of an additional analysis using PSM in DGT patients were consistent with the subgroup analysis results (7.8% vs. 19.4%, p=0.036).


CONCLUSIONS
The current study indicated that the combined prevention of PEP with indomethacin plus PDS was useful in PEP prevention in patients undergoing DGT. Other groups of patients with difficult cannulation may not benefit from the combination strategy.