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EVOLUTION AND EVALUATION OF PANCREATIC SPHINCTEROTOMY IN MANAGEMENT OF RECURRENT PANCREATITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Ananya Prasad¹, Anusha Giri¹, Vinay Chandramouli Bellur¹, Shradha Chervittara Karaveetil¹, Deepika Reddy Aluru², Druvadeep Srinivas³, Ankita Raj², Sravani Bhavanam^*4, Adithya Sathya narayana¹, Advaith N. Rao¹, Swaroop Raj Varma K R^2
1MS Ramaiah Medical College, Bangalore, Karnataka, India; ²Bangalore Medical College and Research Institute, Bangalore, KA, India; ³RajaRajeswari Medical College & Hospital, Bengaluru, KA, India; ⁴Brookdale University Hospital and Medical Center, New York, NY

Introduction:
Recurrent Pancreatitis is described as 2 or more distinct episodes of pancreatitis with complete resolution of symptoms between episodes. Conventionally, it is managed through conservative management which fails to provide adequate relief. Sphincterotomy is the surgical division of the sphincter of Oddi which reduces the pressure of the common duct. It is cost effective and is a safer alternative to cholecystectomy (CC).It is especially effective in prevention of recurrent attacks in elderly patients who have gallstones or are unfit for CC. This study seeks to assess the safety and efficacy of sphincterotomy and to evaluate the outcomes of this procedure through the analysis of existing literature.

Methodology:
The review conducted follows the PRISMA guidelines and major medical databases which include PUBMED, Google Scholar and Science-Direct were searched using a a comprehensive search term to retrieve available articles.The articles which included the assessment of sphincterotomy to treat recurrent pancreatitis were included in the study. The proportion of the population who had recurrence of pancreatitis was assessed as our primary outcome. The proportion of adverse events during the procedure and development of chronic pancreatitis was assessed as secondary outcomes. The data was analysed using the Meta, Metadata and the Metafor packages of R studio.The data was analysed using the Random intercept logistic regression model.Subgroup analysis was conducted based on the type of Sphincterotomy. The confidence interval was estimated by using the Clopper-Pearson method.The I^2 Test evaluated the heterogeneity of the studies.

Results:
The review includes a total of 16 studies with 1120 subjects and 4 subgroups.The risk of relapse to pancreatitis was lowest in the endoscopic sphincterotomy group (0.10[0.03-0.26] ;95% CI ;p<0.01) and ranged variedly among the other groups.The total proportion of relapse to pancreatitis following sphincterotomy is 0.14(0.07-0.26; 95% CI ; p<0.01).The risk of developing chronic pancreatitis following the procedure was low with a proportion of 0.16(0.06-0.36; 95%ci ; p<0.01) developing chronic pancreatitis.The study also highlights that the risk of adverse events associated with the procedure is low with only a total of 0.05 % (0.01-0.24; 95% CI ; p<0.01) subjects having an adverse event(0.01-0.24). Subgroup analysis indicated endoscopic sphincterotomy to be the most optimal procedure in comparison to other techniques.

Conclusion:
Endoscopic Sphincterotomy is a highly effective and safe treatment option for recurrent pancreatitis.Our analysis showed that considerably low percentage of patients who underwent the procedure had recurrent episodes of pancreatitis and had lower risk of developing chronic pancreatitis.Occurance of adverse events was significantly low indicating that the procedure is a safer alternative.

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