ENDOSCOPIC VERSUS SURGICAL VERSUS CONSERVATIVE MANAGEMENT FOR TYPE 2 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) PERFORATIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background
Endoscopic retrograde cholangiopancreatography (ERCP) has become an important therapeutic modality for management of pancreaticobiliary diseases. Post-ERCP perforation, most commonly type 2, is one of the most feared complications of ERCP. In this study, we aimed to assess and compare success rates of conservative, endoscopic, and surgical management of type 2 ERCP perforations.

Methods
A systematic search of Ovid PubMed, Ovid EMBASE, Ovid Scopus, and Web of Science was conducted through November 2023 to identify all studies that reported on conservative, endoscopic, and surgical management strategies for type 2 ERCP perforations. Pooled rates (PR) and 95% confidence intervals (CI) were calculated using a random-effects model. Heterogeneity was evaluated using I2 statistics.

Results
A total of 13 studies with 91,485 patients that underwent ERCP were included in the final analysis. The mean age of the study population ranged from 45–77 years and a significant female predominance was noted. The PR of technical success of ERCP, defined as successful completion of the procedure, was 99.24% (95% Confidence Interval (CI): 98.81-99.58%, I2 97.60).

Type 2 ERCP perforation was noted in 396 patients, of which 268 (67.67%), 22 (5.55%), 29 (7.32%) and 77 (19.44%) underwent conservative, conservative with concurrent percutaneous drain placement, endoscopic and surgical management, respectively. The PR of successful management of the type 2 ERCP perforation was 83.39% (95% CI: 57.51-98.33%, I263) for conservative management alone, 66.65% (95% CI: 12.93-99.92%, I275.46) for conservative management with concurrent percutaneous drain placement, 98.18% (95% CI: 90.63- 99.83%, I20) for endoscopic management, and 83.72% (95% CI: 66.47 - 95.53%, I232.69) for surgical intervention (Table 1).

The PR of mortality of all type 2 ERCP perforations was 11.23% (95% CI: 4.31-20.87%, I273.31). In the conservative management group, a total of 2 deaths (out of 38) were reported from 7 studies. For patients who underwent conservative management with concurrent percutaneous drain placement, 5 patients (out of 10) died per data available from 3 studies. Furthermore, there were a total of 3 deaths (out of 26) for the surgical intervention group from 9 studies. However, there were no reported deaths (out of 28 patients) in the endoscopically managed cohort from 3 studies.

Conclusion
Our findings highlight the excellent success rate and safety of endoscopic management for type 2 ERCP perforations. While surgical intervention remains a viable option with good success rates for management of type 2 ERCP perforations, the mortality was higher than endoscopic management. Therefore, this should be reserved for patients showing clinical deterioration with conservative or endoscopic management. Additional randomized controlled trials are needed to further validate our findings.