VANCOUVER, B.C.—Although the supine position for endoscopic retrograde cholangiopancreatography can be a reasonable choice in a number of circumstances, there were statistical advantages for the prone approach in a multicenter retrospective review.
“Prone ERCP positioning resulted in a higher desired duct cannulation rate, a shorter procedure time and a lower complication rate,” reported Shivani K. Desai, MD, a third-year internal medicine resident at Geisinger Medical Center, in Danville, Pa.
In this study, which won an outstanding poster award at the 2023 annual meeting of the American College of Gastroenterology (abstract P3705), Dr. Desai and her co-investigators evaluated 960 consecutive patients treated at Geisinger, the University of Rochester Medical Center, in New York, and The University of Texas Health Science Center at Houston, from 2018 to 2019. Overall, 465 patients underwent ERCP in the prone position and 495 in the supine position.
The investigators manually extracted demographic and procedural data from medical records and adjusted it by Schultz score (procedural difficulty), American Society of Anesthesiologists physical status classification and anesthesia type. About half of the patients were male and the median age was 64 years.
The rate of successful cannulation was higher (98.7% vs. 95.2%; P=0.0148), the procedure time shorter (22 vs. 32 minutes; P<0.0001) and the complication rate lower (1.3% vs. 3.4%; P=0.0017) among those who underwent ERCP in the prone instead of the supine position, Dr. Desai reported.
However, prone ERCP was associated with a longer fluoroscopy time (5 vs. 1.9 minutes; P<0.0001) and a greater likelihood of intraprocedural cardiovascular instability (64.5% vs. 41.4%; P=0.0035).
Dr. Desai acknowledged that a number of variables cannot be well controlled in a retrospective comparison. One is experience and training, which can create a bias regarding a favored approach. Presuming that patients received the approach preferred by the endoscopist, this relatively large study provided an opportunity to compare the preferred approaches, but Dr. Desai agreed that there are many situations in which the prone position is impractical, such as in patients with abdominal ascites, indwelling catheters, obesity or pregnancy.
“The final determination of patient positioning should be individualized to each patient’s comorbidities and the endoscopist’s expertise,” she said.
A retrospective analysis from the Clinical Outcomes Research Initiative database published three years ago showed the supine position for ERCP was associated with an almost doubled hazard ratio (HR) for an incomplete examination (HR, 1.84; P<0.001). But in that study, procedure time was about 3% shorter with the supine approach (P<0.001).
The authors of that study, led by Juan E. Corral, MD, from Mayo Clinic in Florida, Jacksonville, called ERCP by the supine position “more complicated,” but, like Dr. Desai, they considered that both approaches have a role given considerations like the ones listed by Dr. Desai.
Douglas G. Alder, MD, the director of the Center for Advanced Therapeutic Endoscopy at Porter Adventist Hospital, in Denver, also considers the prone approach preferable except in circumstances where it is impractical. “Most ERCP is performed prone for a lot of good reasons,” he said. However, he added, “even people who prefer prone ERCP occasionally do a case of supine if it is better for the patient.”
—Ted Bosworth
Drs. Adler, Corral and Desai reported no relevant financial disclosures.
This article is from the March 2024 print issue.