Search and Selection

Altogether, 8882 hits were found after duplicate removal, and 2714 patients from 67 studies were included in the review (Fig. 1).

Fig. 1

PRISMA 2020 flowchart of article selection process

Baseline Characteristics

The baseline characteristics of the included studies are shown in Table 1. Of these, 62 were retrospective, and 5 were prospective in design. Seven studies compared two different interventions. A total of 35 studies reported on LA-ERCP, 13 on EDGE, and 12 on EA-ERCP alone.

Table 1 Baseline characteristics of included studies Meta-analysisPrimary Outcomes Technical success

The technical success rate was reported in 12 studies for EDGE [13,14,15,16,17,18,19,20,21,22,23,24], 35 for LA-ERCP [14, 21, 24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56], and 8 for EA-ERCP [16, 52, 57,58,59,60,61,62]. The outcome was achieved in 96% (CI 92–98%; n = 212/214), 93% (CI 91–95%; n = 718/750), and 77% (CI 69–83%; n = 137/176) of patients undergoing EDGE, LA-ERCP, and EA-ERCP, respectively, whereas the heterogeneity measure of total I2 was not substantial (I2 = 0%, CI 0–33%). Subgroup differences were significant between the EA-ERCP and EDGE, and EA-ERCP and LA-ERCP groups (p < 0.05) (Fig. 2, S1A).

Fig. 2

Technical success rates of EDGE, LA-ERCP and EA-ERCP. Summary forest plot of pooled proportions of technical success for each procedure and significant subgroup differences. ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP; CI, confidence interval; I2, total heterogeneity measure

Clinical success

The clinical success was assessed in 11 studies for EDGE [13,14,15,16,17,18,19,20,21, 23, 24], 37 for LA-ERCP [14, 21, 24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56, 63, 64], and 10 for EA-ERCP [14, 16, 52, 57,58,59,60,61,62, 64]. ERCP was successfully performed in 93% (CI 87–97%; n = 182/188), 92% (CI 90–94%; n = 1279/1366), and 64% (CI 56–71%; n = 181/277) of the patients in the EDGE, LA-ERCP, and EA-ERCP groups, respectively. The total I2 value was not substantial (I2 = 14%, CI, 0–60%). Subgroup differences between EDGE or LA-ERCP and EA-ERCP were significant (p < 0.05) (Fig. 3, S2A).

Fig. 3

Clinical success rates of the investigated ERCP techniques. Summary forest plot of the pooled proportions of clinical success for each procedure and significant subgroup differences. ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP; CI, confidence interval; I2, heterogeneity measure

Secondary Outcomes Overall early adverse event rate

A total of 11 studies reported adverse events for EDGE [13,14,15,16,17,18,19, 21,22,23,24], 37 for LA-ERCP [14, 21, 22, 24,25,26,27,28,29,30,31,32,33,34,35,36,37,