ERCP: does patient position count?

Patient Position in Operative Endoscopy

It is well known by surgeons that patient positioning is fundamental to exposing the organs when performing an operation via laparoscopy, as gravity can help move the organs and facilitate the exposure of the surgical site. But is it also important for endoscopic procedures? This paper examines various types of endoscopic operations and addresses the issue of the patient's position. The patient's position can be changed not only by rotating the patient along the head-toe axis but also by tilting the surgical bed, as is undertaken during laparoscopic surgical procedures. In particular, it is useful to take into account the effect of gravity on lesion exposure, tumour traction during dissection, crushing by body weight, risk of sample drop, risk of damage to adjacent organs, and anatomical exposure for procedures with radiological support. The endoscopist should always keep in mind the patient's anatomy and the position of the endoscope during operative procedures, not limited to considering only intraluminal vision.

Endotherapy for Pancreas Divisum

Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.

Clinical outcomes and learning curve for ERCP during advanced endoscopy training: a comparison of supine versus prone positioning

BACKGROUND AND AIMS

No studies have evaluated trainees' outcomes when learning ERCP with patients in the supine and prone positions simultaneously. We aimed to assess whether patient position impacts procedural outcomes and learning curve.

METHODS

We prospectively evaluated patients undergoing ERCP by a supervised advanced endoscopy trainee (AET) at a tertiary care center. Adult patients with native papillae were included. The AET was universally given 5 attempts per cannulation. Outcomes were evaluated quarterly.

RESULTS

Successful cannulation was achieved in 44 supine (69%) and 17 prone (68%) patients (P = .95). Although mean time to reach the papilla was shorter in the supine patient position, time to biliary cannulation (7.8 vs 9.4 minutes, P = .53) and number of attempts were similar. A stepwise increase was seen in cannulation rates throughout the academic year (P < .01) and increased more in supine patients (P = .01). Procedure and total room times were shorter in supine patients.

CONCLUSIONS

Shorter procedure and room turnover times and a comparable cannulation rate were found for supine versus prone ERCP.

Does patient's position count during Endoscopic Retrograde Cholangio-pancreatography? Left lateral decubitus versus prone position

Objective

To compare the efficacy and safety of left lateral decubitus versus prone position during endoscopic retrograde cholangio-pancreaticography (ERCP).

Methods

This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January to June 2021. Patients requiring ERCP were subsequently allotted LL or PP group randomly (unequal randomization) except patients with recent abdominal surgery, in-dwelling catheters, raised intra-abdominal pressure, cervical spine abnormalities and limb contractures. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and student T or Mann Whitney U-test.

Results

A total of 114 patients were enrolled according to the inclusion criteria with 62(54%) males and majority of the patients (42%) belonging to the age group 31-45 years. The most common ERCP indication was choledocholithiasis (36%). Technical success was achieved in 109(96%) patients with no statistically significant difference between the two groups. The total time of procedure, time for deep cannulation, time for acquiring therapeutic goal and ERCP complexity level were all similar between the two groups. The rate of inadvertent PD cannulation and PEP were relatively higher for the PP group but were statistically non-significant through univariate and logistic regression analyses and the only outcome measure that showed significance was multiple cannulations in the PP group.

Conclusion

The study concludes that LL is non-inferior to PP and both positions have comparable outcomes with non-significant differences in terms of technical success rate, complications (specifically PEP), total procedure time, time required for deep cannulation and attainment of goal, ERCP complexity level and inadvertent PD cannulation.

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System

INTRODUCTION AND IMPORTANCE

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities.

CASE PRESENTATION

This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance.

CLINICAL DISCUSSION

Among the 124 patients diagnosed with bile duct stones, thirteen (10.5 %) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4 %. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5 years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4 mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5 min and 183.3 min, respectively. The average length of postoperative hospital stay was 3.5 days, and no instances of mortality or complications were recorded during the study.

CONCLUSION

One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.

Does ERCP position matter? A randomized controlled trial comparing efficacy and complications of left lateral versus prone position (POSITION study)

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally performed with patients in the prone position (PP). However, this poses a potentially increased risk of anesthetic complications. An alternative is the left lateral (LL) decubitus position, which is commonly used for endoscopic procedures. Our aim was to compare cannulation rate, time, and outcomes in ERCP performed in LL versus PP. Patients and methods  We conducted a non-inferiority, prospective, randomized control trial with 1:1 randomization to either LL or PP position. Patients > 18 years of age with native papillae requiring a therapeutic ERCP were recruited between March 2017 and November 2018 in a single tertiary center. Results  A total of 253 patients were randomized; 132 to LL (52.2 %) and 121 to PP (47.8 %). Cannulation rates were 97.0 % in LL vs 99.2 % in PP (difference -2.2 % (one-sided 95 % CI: -5 % to 0.6 %). Median time to biliary cannulation was 03:50 minutes in LL vs 02:57 minutes in PP ( P  = 0.62). Pancreatitis rates were 2.3 % in LL vs 5.8 % in PP ( P  = 0.20). There were significantly lower radiation doses used in PP (0.23 mGy/m ² in LL vs 0.16 mGy/m ² in PP, P  = 0.008) without a difference in fluoroscopy times. Conclusions  Our analysis comparing LL to PP during ERCP shows comparable procedural and anesthetic outcomes, with significantly lower radiation exposure when performed in PP. We conclude that ERCP undertaken in the LL position is not inferior to PP, except for higher radiation exposure, and should be considered as a safe alternate position for patients undergoing ERCP.

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

BACKGROUND

Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.

METHODS

Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.

RESULTS

As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.

CONCLUSION

Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

Patient Positioning Guidelines for Gastrointestinal Endoscopic Procedures

Patient positioning during gastrointestinal endoscopic procedures has received minimal attention compared with surgical procedures performed in the surgical setting. However, prolonged endoscopic interventions on patients and the increasing requirement for general anesthesia have changed to need for patient positioning guidelines. The objective of this study was to test whether patient positioning guidelines for surgical procedures in surgical suites are suitable for gastrointestinal endoscopic procedures without negatively impacting safety and procedure duration. This was an observational feasibility study with volunteers of different body mass index categories. Volunteers were positioned in supine, lateral, and prone positions on an operating table and thereafter on an endoscopy stretcher and asked for comfort levels. Except for arm and head positioning in lateral and prone positions, it was possible to replicate the patient positioning guidelines. Alternative options were explored for the positioning of arms and head to optimize oral access. Besides minor adjustments, we were able to replicate the positioning guidelines and adhere to pressure and nerve injury prevention guidelines. Concept endoscopic patient positioning guidelines were developed. It is recommended to review the "swimmer's" position. Endoscopic patient positioning guidelines should become part of the National Practice Standards and education curriculum of endoscopy nurses.

Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: a retrospective study

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in the prone or supine position. We compared the technical success and other outcomes between these positions.

Methods

This was a retrospective cohort study using the Clinical Outcomes Research Initiative database. Demographics, procedure and fluoroscopy time, visualization of main structures, and technical success rates were compared between the supine and prone positions. Univariate and multivariate regressions were performed to adjust for age, sex, ethnicity and clinical setting.

Results

A total of 21,090 patients who underwent ERCP were included, of whom 1769 (8.4%) were supine and 19,321 (91.6%) were prone. The common bile duct (CBD) was visualized and cannulated in 89.1% of supine vs. 91.4% of prone positions (P=0.017), while the ampulla was visualized in 97.1% of supine vs. 97.7% of prone (P=0.414). The ERCP was incomplete in 10% of supine vs. 5% of prone cases (P<0.001). On multivariate analysis, supine position required shorter procedure times than prone (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.98-0.98; P<0.001). The supine position also yielded lower odds of CBD visualization and cannulation (aOR 0.63, 95%CI 0.44-0.91; P=0.011) and higher odds of an incomplete examination (aOR 1.84, 95%CI 1.46-2.30; P<0.001) vs. prone.

Conclusions

The supine position leads to shorter procedures but is more likely to result in poorer visualization and cannulation of the CBD and an incomplete examination. This may reflect the technical difficulty of performing ERCP in the supine position for the endoscopist. Our study supports recommendations for an individualized ERCP approach.