Nitroglycerin For The Prevention Of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis:A Meta-analysis

Objective:To evaluate the effectiveness of nitroglycerin in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis（PEP）and provide the reference for the clinic by conducting a meta-analysis of clinical studies.Methods:Two researchers independently searched Pubmed,Embase,Cochrane Library,Web of science,Chinese Biomedical Literature Database（CBM）,China National Knowledge Infrastructure（CNKI）and Wanfang Database from inception to November 30,2016 for all clinical literatures on nitroglycerin for the prevention of PEP.Screened studies based on the present inclusion and exclusion criteria and extracted data.The quality evaluation was carried out by the method of Cochrane Collaboration and the review manager 5.3 was used for statistical analysis.Different routes,dosages,severity of PEP and regions may influence its effectiveness.Based on these hypothesis,we performed subgroup meta-analysis of these trials.To prove the stability and reliability of the outcome in the method of publication bias.According to these results of meta analysis to draw conclusions.Results: Thirteen clinical trials with a total number of 2695 patients（nitroglycerin group1339 cases,control group 1356 cases）evaluating the incidence of PEP after administration of nitroglycerin were identified.The meta-analysis showed the overall incidence of PEP was reduced by glyceryl trinitrate treatment [RR = 0.62,95%CI（0.48-0.80）,P =0.0002].Subgroup analysis:（1）The severity of PEP.Six randomized controlled trials with a total number of 1809 cases（experimental group 899 cases,control group 910cases）suggested that no statistical significance in reducing the incidence of mild ERCP pancreatitis [RR = 0.77,95%CI（0.52-1.15）,P = 0.20].Five clinical trials with a total number of 1621 cases（experimental group 805 cases,control group 816 cases）suggested that no statistical significance in reducing the incidence of moderate-severe PEP[RR=0.70,95%CI（0.42-1.15）,P = 0.16];（2）The route of administration.The sublingual route was associated with statistically significantly reduced rates of PEP [RR = 0.40,95%CI（0.25-0.63）,P<0.001].The transdermal and topical application suggested that no statistical significance in reducing the incidence of PEP（[RR1=0.78,95%CI1（0.55-1.10）,P1=0.16];[RR₂=1.00,95%CI2（0.28-3.53）,P2=1.00]）;（3）The dosage.The group 1（<5mg）was associated with statistically significantly reduced rates of PEP [RR = 0.50,95%CI（0.33-0.78）,P = 0.002].The group 2（5-10mg）and the group 3（15mg）suggested these dosage may not be useful for PEP reduction（[RR1=0.73,95%CI1（0.48-1.11）,P1=0.14];[RR₂ = 0.64,95%CI2（0.41-1.02）,P2 = 0.06]）;（4）The region.Asia and Europe were associated with statistically significantly reduced rates of PEP（[RR1 = 0.52,95%CI1（0.33-0.79）,P1=0.003;RR₂=0.56,95%CI2（0.39-0.81）,P2=0.002]）.Conclusion: Nitroglycerin can prevent the occurrence of post-endoscopic retrograde cholangiopancreatography pancreatitis（PEP）,and the most effective route is sublingual administration.The main side effects attributable to nitroglycerin were hypotension and headache,and responded to conventional treatment.