Optimal Positioning for ERCP: Efficacy and Safety of ERCP in Prone versus Left Lateral Decubitus Position

Background. ERCP is customarily performed with the patient in prone position. For patients intolerant of prone positioning, ERCP in left lateral decubitus (LLD) position offers a potential alternative. Aims. To compare efficacy and safety of ERCP in the LLD position versus prone position. Methods. Consecutive ERCP reports from August 2009 to October 2010 at Mayo Clinic Arizona were reviewed. Inclusion criteria. Age？>？18 years, native papilla, and biliary indication. Primary outcome measure. Bile duct cannulation rate. Secondary outcomes. Times to ampullary localization and bile duct cannulation and complication rate. Results. ERCPs reviewed from 59 patients in two positions: 39 prone and 20 LLD. Cannulation Rate. 100% prone versus 90% in LLD ( ). Median (IRQ) times. (1) Ampullary localization: 90？sec (70–110) prone versus 100？sec (80–118) ( ); (2) bile duct cannulation: 140？sec (45–350) prone versus 165？sec (55–418) LLD ( ). Complications. No periprocedure; postprocedure 4 (10%) prone versus 3 (15%) LLD ( ). Conclusion. ERCP performed in LLD position allowed deep bile duct cannulation in 90% of patients without significantly increased procedural times or rate of complications as compared to prone position. 1. Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is conventionally performed in the prone position; this allows for easier passage of scope through the pharynx and low risk of aspiration for the patient and provides an effective and comfortable approach for the endoscopist [1]. However, the prone position is not always optimal or possible, especially for patients with abdominal distension or tenderness due to tense ascites, indwelling percutaneous catheters, morbid obesity, advanced pregnancy, or recent abdominal surgery [2, 3]. In addition, patients with limited neck mobility who require deep sedation with endotracheal anesthesia may not be able to turn their neck laterally to accommodate the endotracheal tube. Several studies have reported outcomes and safety of ERCP in the supine position as an alternative to standard prone positioning. Ferreira and Baron concluded that an ERCP with the patient in the supine position can be safely and effectively performed if necessitated by clinical circumstances [4], though the supine position can be less comfortable for the endoscopist. This conclusion was different from that reached by the Terruzzi and colleagues who reported that difficult cannulation was markedly increased in the supine position, and cardiopulmonary adverse events were more frequent in this group [5]. The left lateral