Pure cut vs. Endocut in endoscopic biliary sphincterotomy: Systematic review and meta-analysis of randomized clinical trials

Background and study aims Biliary sphincterotomy is a crucial step in endoscopic retrograde cholangiopancreatography (ERCP), a procedure known to carry a 5% to 10% risk of complications. The relationship between Pure cut, Endocut, post-ERCP pancreatitis (PEP) and bleeding is unclear. This systematic review and meta-analysis compared these two current types and their relationships with adverse events. Patients and methods This systematic review involved searching articles in multiple databases until August 2023 comparing pure cut versus Endocut in biliary sphincterotomy. The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results A total of 987 patients from four randomized controlled trials were included. Overall pancreatitis: A higher risk of pancreatitis was found in the Endocut group than in the Pure cut group (P=0.001, RD=0.04 [range, 0.01 to 0.06]; I-2=29%). Overall immediate bleeding: Statistical significance was found to favor Endocut, (P=0.05; RD=-0.15 [range, -0.29 to -0.00]; I-2=93%). No statistical significance between current modes was found in immediate bleeding without endoscopic intervention (P=0.10; RD=-0.13 [range, -0.29 to 0.02]; I-2=88%), immediate bleeding with endoscopic intervention (P=0.06; RD=-0.07 [range, -0.14 to 0.00]; I-2=76%), delayed bleeding (P=0.40; RD=0.01 [range, -0.02 to 0.05]; I-2=72%), zipper cut (P=0.58; RD=-0.03 [range, -0.16 to 0.09]; I-2=97%), perforation (P=1.00; RD=0.00 [range, -0.01 to 0.01]; I-2=0%) and cholangitis (P=0.77; RD=0.00 [range, -0.01 to 0.02]; I-2=29%). Conclusions The available data in the literature show that Endocut carries an increased risk for PEP and does not prevent delayed or clinically significant bleeding, although it prevents intraprocedural bleeding. Based on such findings, Pure cut should be the preferred electric current mode for biliary sphincterotomy.