Rectal indomethacin alone versus combined with prophylactic pancreatic duct stenting for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: a systematic review and meta-analysis.

Authors

Luis E Cueva-Cañola, Karoly P Zuñiga-Montaño, Andrea C Beltran-De la Fuente, Wilmer E Díaz-Gutierrez, Oscar Eduardo Camacho-Hernández, Yverong Gu

Published in

European journal of gastroenterology & hepatology. Jul 29, 2026. Epub Jul 29, 2026.

Abstract

Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most frequent complication of ERCP, particularly in high-risk patients. Although rectal indomethacin and prophylactic pancreatic duct stenting (PDS) independently reduce PEP risk, the incremental benefit of combining both strategies remains uncertain. This meta-analysis evaluates the effectiveness of rectal indomethacin alone versus indomethacin plus prophylactic PDS for PEP prevention in high-risk patients.
PubMed, Embase, Ovid/MEDLINE, and the Cochrane Library were searched from inception through 28 January 2026. Randomized controlled trials (RCTs) and cohort studies comparing rectal indomethacin alone with indomethacin plus prophylactic PDS in high-risk ERCP patients were included. Risk ratios with 95% confidence intervals (CI) were pooled using a random-effects model. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework.
Six studies (three RCTs and three cohort studies) including 3753 patients were analyzed. Overall, PEP occurred less frequently with combination prophylaxis than with indomethacin alone (risk ratio = 0·73, 95% CI: 0·60-0·89, I2 = 9%). Reductions were also observed for mild PEP (risk ratio = 0·73, 95% CI: 0·58-0·93, I2 = 0%) and moderate-to-severe PEP (risk ratio = 0·73, 95% CI: 0·55-0·98, I2 = 0%). The protective effect on overall PEP was confirmed in analyses restricted to RCTs. Based on randomized evidence, the certainty of the evidence was moderate.
In high-risk ERCP patients, adding prophylactic PDS to rectal indomethacin was associated with a reduced incidence of PEP compared with indomethacin alone.

PMID:
42742970
Bibliographic data and abstract were imported from PubMed on 16 Sep 2026.

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