Skip to main content
NCBI home page
Lippincott Open Access logoLink to Lippincott Open Access
. 2025 Jan 27;48(1):51–61. doi: 10.1097/SGA.0000000000000849

A Randomized Controlled Trial of Patient Positioning During Endoscopic Retrograde Cholangiopancreatography (ERCP) Procedures

A Comparison Between Semi-Prone- and Prone-Positioned Patients

Vera Meeusen 1,2,3, Mijin Kim 1,2,3, Regan Ma 1,2,3, Marilyn Roque 1,2,3, Pal Sivalingam 1,2,3, Zaki Hamarneh 1,2,3, Luke Hourigan 1,2,3
PMCID: PMC11776873  PMID: 39874119

Abstract

The prone “swimmers” position is preferable for endoscopic retrograde cholangiopancreatography (ERCP) as it provides the best visualization for selective bile duct cannulation. However, “swimmers” position does not comply with best-practice patient positioning guidelines. Our objective was to determine whether the semi-prone patient position was suitable for ERCP without negatively influencing the outcomes of the procedure. We conducted a randomized controlled trial, 50 patients in prone and 50 patients in semi-prone patient position, measuring the number of attempts and time to successfully cannulate the bile duct. Safety outcomes measured were airway access, pharyngeal endoscope passage, and complications. Between the two groups, there were no statistical differences in demographic variables, selective bile duct cannulation attempts, or cannulation time. Airway access scored significantly better in the semi-prone position. There was a significant positive correlation between the total number of cannulation attempts and papilla type. No intra- or post-procedural significant complications occurred. The semi-prone position was comparable to the “swimmers” position regarding the number of attempts and time required for selective bile duct cannulation but scored significantly better in airway access by anesthetists. A semi-prone patient position is advisable for ERCP procedures as it complies with best-practice patient positioning guidelines.

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in diagnosis and treatment of pancreatic–biliary diseases. The procedure requires radiographic support and is often performed in the endoscopy unit instead of an operating room. The key issues concerning ERCP include selective bile duct cannulation, the prevention of post-ERCP pancreatitis (PEP) that occurs in 2%–16% of ERCP procedures, airway management, and comfortable patient positioning (Johnson et al., 2020). In general, patients for ERCP procedure can be positioned supine, lateral, and/or prone. The positioning technique is often decided based on multiple factors including the expected technical complexity of the ERCP procedure, anesthesia requirements, and patient’s comorbidities.

Background

From a technical perspective, prone positioning of the patient is favorable as it facilitates biliary duct cannulation and offers a better view of the biliary and pancreatic radiological anatomy with less ocular-radiation exposure during fluoroscopy, as well as optimizes the position of the ampulla of Vater (Angsuwatcharakon et al., 2018; Froehlich, 2006; Maydeo & Patil, 2018; Osagiede et al., 2021; Terruzzi, Radaelli, Meucci, & Minoli, 2005). The left lateral position, however, allows easier passage of the duodenoscope through the pharynx and facilitates progress into the duodenum while being more comfortable for the patient (García-Cano, 2018; Park et al., 2017). Unfortunately, the lateral position can decrease the success rate of cannulation as the common biliary duct and pancreatic duct may overlap or be visible in a reverse position (main pancreatic duct left and common bile duct right) fluoroscopically (Terruzzi et al., 2005), and higher rates of unintended pancreatic duct cannulation and contrast injection may occur (Park et al., 2017). Alam, Khan, Saeed, Sher, and Khan (2023) did not find any difference between lateral or prone positioning regarding the time of procedure and bile duct cannulation time.

There is a consensus that the success rate of bile duct cannulation is also decreased in the supine position (Ferreira & Baron, 2008; Mashiana, Jayaraj, Mohan, Ohning, & Adler, 2018; Osagiede et al., 2021; Terruzzi et al., 2005). Tringali, Mutignani, Milano, Perri, and Costamagna (2008) found no difference in cannulation or adverse events when performing ERCP under sedation in a supine or prone position. However, during visualization of the papilla with a patient in the supine position, the endoscopist needed to face away from the patient due to camera orientation or turn the handle of the scope 90° clockwise (Osagiede et al., 2021; Tringali et al., 2008). A systematic review comparing prone and supine patient positioning during ERCP showed a higher technical success rate in the prone position and similar rates of adverse events, including cardiovascular complications and PEP (Mashiana et al., 2018).

From an anesthetic point of view, the prone position has the disadvantage that it can decrease blood flow in the vena cava and mesenteric veins and alter the cerebral blood flow in patients with existing cerebral perfusion problems (Froehlich, 2006). Patients also have a higher incidence of cardiopulmonary complications such as hypoxia and bradycardia (Froehlich, 2006; García-Cano, 2018; Terruzzi et al., 2005). Although the prone position prevents aspiration of gastric contents, lateral and supine positions provide easy oral access in case urgent airway access is required, which can be beneficial if the sedation is provided by the endoscopist and not an anesthetic team (Chandrasekhara et al., 2017). Intravenous sedation without endotracheal intubation is adequate for most ERCP procedures (Schumann et al., 2016; Yuen, Xia, Chan, Yan, & Irwin, 2016); however, inadequate sedation levels were reported to account for more than 60% of ERCP complications (Raymondos et al., 2002; Williams et al., 2007), and conversion to general anesthesia may be necessary at any time (Yuen et al., 2016).

Both lateral and supine positions are more comfortable for the patient (Alcivar-Leon, Nieto-Orellana, Jara-Alba, & Marriott-Diaz, 2017; Meeusen et al., 2021). The left lateral position is often chosen when patients have limited cervical spine movement (Park et al., 2017). Supine position may be preferable if patients suffer from severe abdominal pain or distension, a large amount of ascites, recent abdominal or cervical spine surgery, intra-abdominal catheter insertion, or severe obesity.

Often the “swimmers” position, a modified prone position, is preferred during ERCP procedures. In this position, the left arm is positioned next to the body, and the elbow of the right arm is flexed with the shoulder abducted well beyond a 90° angle. This overextension of the shoulder can cause considerable damage to the brachial plexus nerve and vascular decompression at the thoracic outlet of the subclavian arteries and veins (Association of Perioperative Registered Nurses (AORN), 2022; Chen, Doornbos, Williams, & Criado, 2014; Meeusen, Rogue, & Elson, 2019; Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies, 2018; Sawyer, Richmond, Hickey, & Jarrratt, 2000; Welch et al., 2009). The positioning of the right arm in the “swimmers” position is exactly doing this, which makes the “swimmers” position a high-risk position for nerve and vascular damage. Another option would be to place the patient in prone position, both arms next to the body, head straight, and two padded chest rolls placed from the clavicle to pelvic bones to raise the torso for chest expansion, but this is only recommended for patients having a general anesthetic with endotracheal intubation (Association of Perioperative Registered Nurses (AORN), 2022; Meeusen et al., 2021).

A recent study among volunteers demonstrated low patient satisfaction scores for prone positioning, but when slightly modifying this into a semi-prone position, it was better tolerated (Meeusen et al., 2021). The semi-prone patient position could potentially offer a solution by maintaining the anesthesia and endoscopic advantages of the prone patient position while complying with evidence-based patient positioning guidelines (Association of Perioperative Registered Nurses (AORN), 2022; Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies, 2018). First, we hypothesized that patients in a semi-prone position during ERCP will have similar selective bile duct cannulation success rates and cannulation times compared to the patients in the prone position; and second, the semi-prone position during ERCP will allow easy access to the airway and passage of the endoscope through the pharynx compared to patients in the prone position. The aim of this study was to compare the safety and efficacy of prone and semi-prone patient positions during ERCP procedures with the main objective to determine whether the semi-prone patient position is suitable for ERCP without negatively influencing the patient or the endoscopic and anesthetic outcomes of the procedure.

Materials and Methods

This research project was a randomized controlled trial, testing 50 patients in the prone position (group A) and 50 patients in the semi-prone patient position (group B). The study was conducted in the endoscopy unit of the Princess Alexandra Hospital, Queensland, Australia, and ethics approval was obtained from the Metro South Health Human Research Ethics Committee. The research project was conducted in full conformance with principles of the “Declaration of Helsinki,” Good Clinical Practice, and within the laws and regulations of Australia (National Health and Medical Research Council et al., 2018a, 2018b; World Medical Association, 2001).

Population

Patients aged 18 years and above who were scheduled for an ERCP procedure at the Princess Alexandra Hospital were screened by one of the researchers for inclusion criteria on the day of the procedure. Patients who were unable to consent, patients speaking a language other than English without an interpreter, and patients unable to undergo the procedure under sedation with high flow oxygen therapy (this was at the anesthetist’s discretion) were excluded from the study. See Table 1 for the complete list of inclusion and exclusion criteria.

TABLE 1.

Inclusion and Exclusion Criteria for the Study

Inclusion Criteria Exclusion Criteria

  • Biliary duct stone(s)

  • Gallstone pancreatitis

  • Obstructive jaundice due to malignancy

  • Benign biliary stricture

  • Altered gastric and duodenal anatomy due to intra-abdominal surgery (e.g., Billroth gastrectomy and total gastrectomy)

  • Intended cannulation of the minor papilla

  • Presence of duodenal strictures

  • Severe infections or hemodynamic instability

  • Recent myocardial infarction (within 6 months) or uncontrolled arrhythmia, unstable angina, or congestive heart failure

  • Severe neurologic disease

  • Conditions that increased the difficulty of the use of the prone position (e.g., severe abdominal pain, severe abdominal distension, extensive ascites, neck surgery)

  • Pregnancy

  • Pancreatogram requirement
Open in a new tab

Anesthetic Technique

All patients received sedation with intravenous administration of propofol, potentially in combination with alfentanil or fentanyl, and midazolam. Patients received high flow oxygen therapy using a nasal cannula (Optiflow from Fisher & Paykel) and minimum monitoring requirements included an electrocardiogram, peripheral pulse oximetry, respiratory rate, end tidal CO2, and noninvasive blood pressure.

Patient Positioning

The patients in group A were positioned in the semi-prone position (Figure 1) using a wedge pillow (Abecca patient wedge, 850 × 450 × 110–40 mm, from Select Patient Care, Maryborough, Queensland, Australia). In this semi-prone position, the thorax and abdomen are placed in a 30° prone tilt position with the left arm next to the body, the right elbow flexed, with limited shoulder abduction so that the right elbow is still below shoulder level. The left leg is positioned straight with a pillow under the shin to protect the foot, and the right leg is slightly flexed with a pillow underneath the knee to support the leg and foot. The patients in group B were positioned as per normal routine in the so-called “swimmers” position (Figure 2). The left arm was positioned next to the body, and the right elbow was flexed with the shoulder abducted well beyond a 90° angle. No extra pillows to support the thorax or abdomen were used. A pillow was positioned under the legs of the patient to protect the feet. For both groups, the head was positioned on the same level as the thorax by using an appropriately sized flexible open horseshoe head ring. Arms, especially elbows, were protected from contact with the bed trolley with (HMS Medical, Brendale, Australia), and legs/feet were supported by regular pillows.

FIGURE 1.

FIGURE 1.

Open in a new tab

Patient in semi-prone position using a wedge pillow to support thorax and abdomen. In this semi-prone position, the thorax and abdomen are placed in a 30° prone tilt position with the left arm next to the body and the right elbow flexed, with limited shoulder abduction so that the elbow is still below shoulder level.

FIGURE 2.

FIGURE 2.

Open in a new tab

Patient in the prone so-called “swimmers” position. The left arm was positioned next to the body, and the right arm was flexed and shoulder abducted well beyond a 90° angle with the shoulder. No extra pillows to support thorax or abdomen were used.

Measurements

Outcome measurements for the first hypothesis included the number of cannulation attempts by the fellow, number of cannulation attempts by the consultant, total number of cannulation attempts, and time in minutes from endoscope intubation until successful selective cannulation of the bile duct. Successful selective cannulation of the bile duct was measured as the number of cannulation attempts and the time to successful cannulation (Swan et al., 2013). One cannulation attempt was defined as sustained contact between the sphincterotome and the papilla for at least 5 s (Swan et al., 2013). The biliary duct cannulation time was defined as the time from endoscope intubation until free, and deep instrumentation of the biliary tree was obtained.

For the second hypothesis, outcome variables were ease of access to the airway, which was assessed by the anesthesiologist, and ease of oral access and pharyngeal duodenoscope passage through the pharynx into the esophagus, which was assessed by the endoscopist. All assessments were measured on a six-point Likert scale (1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good, and 6 = excellent).

Demographic control variables collected were age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) classification, use of antiplatelets on the day of the procedure, cardiopulmonary comorbidities, and whether the patient had a previous sphincterotomy or papillary balloon dilatation.

Procedure related control variables were ERCP indication, ease of patient positioning assessed by the nursing team, initial endoscopist (endoscopist who started the procedure and performed the first cannulation attempt), conversion required to general anesthesia with supraglottic airway device (LMA Gastro) or endotracheal tube or conversion required to different patient position, conversion from fellow to consultant during cannulation, sphincter therapy, clinical success (defined as success in the acquisition of the therapeutic goals), and type of papilla as per Haraldsson’s classification, and consultant or fellow performing the procedure. Haraldsson’s classification for different types of papillae was validated in 2016 and defined type 1 as a regular papilla with no distinctive features (“classic appearance”), type 2 as a small papilla with a diameter not bigger than 3 mm, type 3 as a protruding or pendulous papilla, and type 4 as a creased or ridged papilla (Haraldsson et al., 2017).

Adverse events during the procedure and recovery phase were constantly monitored. Events captured were classified as septic shower, bleeding, perforation, basket impaction, pressure and skin injuries or nerve damage, and/or cardiovascular or pulmonary incident. Transient episodes of hypoxia and/or hypotension were excluded (Chandrasekhara et al., 2017).

Process

Patients were scheduled for their procedures after triage based on clinical priority. If the patient satisfied the inclusion criteria, they were informed about the study and an informed consent was obtained. Using a computer-generated randomization list, patients were randomly assigned to group A (semi-prone) or B (prone). The patients were positioned as per the allocated research group while still awake and after induction, but administered indomethacin rectally (as per normal routine) before the procedure.

The ERCP was performed using a conventional duodenoscope (TJF 240 or 260V, Olympus Optical Co., Ltd., Tokyo, Japan). Selective bile duct cannulation was performed using wire-guided cannulation, and in case of difficult cannulation, needle knife sphincterotomy was performed if required for biliary access. After selective cannulation, a cholangiogram was obtained, and biliary sphincterotomy was performed. Balloon sphincteroplasty was also performed if indicated. Post-procedurally, in recovery just before discharge, the patient was assessed for pressure and skin injuries and nerve damage. Post-procedural care was as per standard care and similar in both groups. All control and outcome variables were recorded on a research form.

Statistical Analysis

All participants were given an anonymous participant ID code, and personal identifiers of the participants were not recorded. Data were collected and analyzed with a dedicated statistical computer program (Statistical Package for the Social Sciences, SPSS 27.0). Differences between groups were evaluated using t-test for nonparametric data. Similar research projects had sample sizes ranging from 34 to 120 (Angsuwatcharakon et al., 2018; Park et al., 2017; Terruzzi et al., 2005; Tringali et al., 2008). Based on these studies, 50 patients per group (total sample size is 100) were included. This sample size would demonstrate a statistically significant difference between groups, assuming a b-value equal to 0.80 and a probability value of <.05. Statistical significance was assumed when p value is <.05.

Results

In total, 100 patients underwent an ERCP procedure of which 47 females and 53 males were equally divided among both groups. Two patients were initially included in the prone study group but required lateral positioning during the initial patient positioning and were therefore excluded from the study and replaced by two new enrollments. There were no statistical differences in demographic variables between the two groups. The average age of the participants was 61 (SD = 17.4), with an average BMI of 29.83 (SD = 9.71) and ASA classification 2.16 (SD = 0.71), 48% of the patients used antiplatelets medication on the day of the procedure, and 65% of the cases had at least one cardiopulmonary comorbidity. Most ERCP procedures were indicated for choledocholithiasis (Table 2). Two percent of the cases had a sphincter dilatation and 31% had a sphincterotomy during a previous ERCP procedure. In 22% of the 48 cases where a fellow started the procedure, a consultant took over during cannulation, and in total 4% of the cases were unsuccessful.

TABLE 2.

Indications for ERCP in 100 Patients

Indication N
Choledocholithiasis 47
Biliary malignancy 14
Direct post-cholecystectomy complications 10
Pancreatic tumor 9
Sclerosing cholangitis 6
Biliary obstructions after liver transplant 6
Blocked biliary stents 5
Chronic pancreatitis 3
Open in a new tab

Although 96% of the procedures were successful, unsuccessful procedures (two patients in group A and two in group B) were significantly longer than successful procedures, mean of 62 min versus 31 min for the time between duodenoscope insertion and duodenoscope removal, and the average age of these patients was significantly older (76.8 vs. 60.3). One patient in the prone position, not using any antiplatelets, suffered from bleeding during sphincterotomy and this was managed intra-procedurally without further post-procedural complications. There was no incident of changing patient positions or anesthetic techniques.

There was no statistical difference between the two groups regarding the control and demographic variables but the two-tailed T-test showed a significant correlation between patient position and whether the procedure was performed by a fellow or consultant. Therefore, partial correlation was performed, controlled for the variable “initial endoscopist.” The patient’s position was not significantly correlated with any of the outcome variables of selective biliary duct cannulation attempts and cannulation time (Table 3). However, airway access as assessed by the anesthesiologist scored significantly better in the semi-prone position and was positively correlated with the ease of oral access and pharynx passage of the endoscope as assessed by the endoscopist. Despite this, ease of oral access and pharynx passage was not significantly different among both groups. The consultant-endoscopists demonstrated significantly fewer cannulation attempts in cases with higher scores for ease of oral access (t[96] = 0.209).

TABLE 3.

Partial Correlation Between Patient Position and Outcome Variables Controlled for the Variable “Initial Endoscopist” (Two-Tailed). Outcome Variables: Position (1 = Semi-Prone, 2 = Prone), Oral Access, Pharynx Passage, Airway Access and Ease of Positioning (1 = Very Poor, 2 = Poor, 3 = Fair, 4 = Good, 5 = Very Good, 6 = Excellent), Type of Papilla (Haraldsson’s Classification 1–4), Number of Cannulation Attempts by the Fellow, Number of Cannulation Attempts by the Consultant, Total Number of Cannulation Attempts, Requirement for Sphincterotomy (No = 0, Yes = 1), and Time Required for Successful Cannulation of the Common Bile Duct

1 2 3 4 5 6 7 8 9 10 11

1. Position

 1

2. Oral access

 −0.037 1

3. Pharynx passage

 0.034 0.837 1

4. Airway access

 −0.263b 0.27b 0.309b 1

5. Ease of patient positioning

 −0.174 0.391 0.414 0.512 1

6. Type of papilla

 0.101 −0.058 −0.047 0.114 0.136 1

7. Cannulation attempts by fellow

 0.118 −0.028 −0.11 −0.053 0.158 0.191 1

8. Total cannulation attemptsby consultant

 0.035 −0.132 −0.143 −0.02 −0.027 0.308b 0.509 1

9. Total cannulation attempts

 0.08 −0.101 −0.148 −0.039 0.059 0.296b 0.821 0.91 1

10. Sphincterotomy required

 0.16 0.052 0.042 −0.18 0.093 0.247a 0.24a 0.269b 0.294b 1

11. Time for successfulcannulation

 0.155 −0.164 −0.151 −0.259a −0.066 0.18 0.331c 0.392 0.42 0.213a 1
Open in a new tab
a

Significant at level p < .05

b

p < .01

c

p < .001

The total number of attempts was significantly positively correlated with cannulation time, the type of papilla, previously performed sphincterotomy, and the use of a sphincterotome or needle knife to facilitate biliary access during the procedure. A partial correlation controlled for previously performed sphincterotomy demonstrated a significant positive correlation between the total number of cannulation attempts and type of papilla, as well as the time it took to cannulate the selective bile duct successfully (Table 4). The mean and standard deviation of the number of cannulation attempts for the different types of papillae were type 1 (M = 2.35, SD = 2.74, N = 65), type 2 (M = 5.82, SD = 4.67, N = 11), type 3 (M = 4.45, SD = 3.62, N = 20), and type 4 (M = 6.25 and SD = 3.86, N = 4).

TABLE 4.

Pearson Correlation (Two-Tailed) Between Patient Position and Outcome Variables in Patients Without Previously Performed Sphincterotomy or Dilatation (N = 67). Outcome Variables: Position (1 = Semi-Prone and 2 = Prone), American Society of Anesthesiology (ASA) Classification, Type of Papilla (Haraldsson’s Classification 1–4), Number of Cannulation Attempts by the Fellow, Number of Cannulation Attempts by the Consultant, Total Number of Cannulation Attempts, and Time Required for Successful Cannulation of the Common Bile Duct

1 2 3 4 5 6 7

  1. Patient position

 1

2. ASA class

 −0.08 1

3. Type of papilla

 −0.032 0.183 1

4. Cannulation attempts fellow

 −0.119 0.308a 0.219 1

5. Cannulation attempts consultant

 0.017 0.259a 0.163 0.031 1

6. Total cannulation attempts

 −0.058 0.388b 0.259a 0.625b 0.800b 1

7. Time for successful cannulation

 0.191 0.099 0.088 0.192 0.337b 0.349b 1
Open in a new tab
a

Significant at level p < .05

b

p < .01

Discussion

This study tested a semi-prone patient position against the currently used “swimmers” position during ERCP procedures. Although the “swimmers” position is often preferred over supine and lateral position, in this position the patients are vulnerable to the development of brachial plexus nerve injuries due to shoulder overextension (Sawyer et al., 2000) and vascular decompression of the subclavian arteries and veins (Chen et al., 2014). Both of our hypotheses were confirmed.

The tested semi-prone position scored equally well regarding the number of selective bile duct cannulation attempts and cannulation time and scored significantly better by anesthetists for airway access. Both are very relevant in the prevention of ERCP complications. Interestingly, the patient’s position is often not mentioned as a risk factor in the overview or systemic reviews regarding ERCP complications and their management (Chandrasekhara et al., 2017; Freeman, 2012; Johnson et al., 2020; Talukdar, 2016).

Others have reported visualization issues causing a decreased biliary access rate when patients were placed in a lateral position (Froehlich, 2006; Park et al., 2017). Froelich managed to deal with this problem by using a mobile radiography system that allowed a horizontal, back-to-front of the patient, direction for the beam (Froehlich, 2006). Others suggest placing a plastic pancreatic stent with radiological marker in the main pancreatic duct facilitating pancreatic position and thereafter cannulating the common bile duct, especially in patients with a high risk of developing PEP (Afghani et al., 2014; Freeman, 2021; García-Cano, 2018; Johnson et al., 2020).

The semi-prone-positioned patients scored significantly better in airway accessibility by the anesthesiologist. Comparing the head positions, the semi-prone position seems to require less head rotation (and thus less extension of the left brachial nerve) as the whole upper body is already slightly tilted on the right side. In the semi-prone position, the position of the right arm does not obstruct access to the airway as the hand and elbow are positioned well below the shoulder level. Potentially the semi-prone position is, from an anesthesia perspective, offering the best of the prone and lateral positions combined. The semi-prone position may still protect the patient from aspiration, which is currently seen as an advantage of the prone position but at the same time does not obstruct access to the airway and overextend the brachial nerve to the same degree as the prone “swimmers” position.

No pressure injuries or neurological damage were established in the recovery post-procedurally. We only assessed patients for these injuries in the recovery area, though the pressure and nerve injuries may be visible and experienced in a later stage (National Pressure Injury Advisory Panel et al., 2019). Pressure injuries are localized injuries to the skin and/or underlying tissue due to disruption of tissue perfusion resulting from sustained pressure >32 mm Hg [33, 34] with an increased risk in obese patients (Delmore & Ayello, 2017).

Unfortunately, an 83-year-old male patient from group B developed a pressure injury under the left eye. The facial soft tissue injury was caused by the Optiflow tube, which was left incorrectly under the patient’s left cheek. This injury was followed-up by the nursing team and completely healed on the second day post-procedure.

In 2017, Haraldsson et al. (2017) proposed a classification to describe the different macroscopic appearances of the papilla as this affects cannulation complexity. This study confirmed these findings as type 1 papilla (no distinctive features) had significantly fewer cannulation attempts. Despite a large majority of the patients having a type 1 papilla, sphincterotomy/sphincteroplasty (sphincterotomy, dilatation or needle knife) was required in 65% of the cases. The risk of PEP may be decreased when difficult cannulation is recognized, and early application of pre-cut is performed (Chandrasekhara et al., 2017; Johnson et al., 2020; Swan et al., 2013). Our study demonstrated on average three cannulation attempts, which were well below the seven attempts that correlated with an increased risk of PEP (Swan et al., 2013), which is the most common complication with an overall incidence of almost 10% and mortality rate of 0.7% (Thaker, Mosko, & Berzin, 2015). Chen et al. (2020) found that small papilla (type 2) and protruding or pendulous papilla (type 3) were more difficult to cannulate. Until now, patient-related risk factors for PEP included considerations such as female gender, youthful age, and sphincter of Oddi dysfunction, but maybe the type of papilla should be included. Like Chen et al. (2020), this study suggests that papillae type 2, 3, and 4 may benefit from early sphincterotomy intervention to prevent PEP. However, mean values for the number of cannulation attempts of all types of papillae was below 8, which is often considered a difficult cannulation (Talukdar, 2016).

With the positive outcome of this study, the semi-prone position can potentially be implemented as the new standard for safe and efficient patient positioning during ERCP procedures. Further studies are required to determine patient satisfaction in the semi-prone position and solidify the outcomes achieved on a larger scale.

Conclusions

In conclusion, the semi-prone position was comparable to the currently used “swimmers” position regarding selective bile duct cannulation attempts and the time it took for successful cannulation. The semi-prone position scored significantly better in airway access by anesthesiologists. Findings suggest that the semi-prone position should be promoted during ERCP procedures as it facilitates airway access, complies with patient positioning best-practice guidelines, and therefore prevents pressure, nerve, and tissue damage of the brachial plexus nerve without negatively impacting selective bile duct cannulation and the risk of post-ERCP pancreatitis. While further studies are indicated to establish generalizable findings, the development and implementation of patient positioning guidelines for endoscopic procedures, especially for ERCP procedures, would be beneficial for these patients.

Footnotes

Funding : This research project was funded by the Endoscopy Unit of the Princess Alexandra Hospital, Australia.

The authors have read the manuscript and prepared and revised the manuscript according to the CONSORT 2010 Checklist.

All authors read and approved the final manuscript. V.M., L.H., and M.K. conceived and designed the project. R.M., M.R., and V.M. collected data. V.M., P.S., and M.K. analyzed, validated, and interpreted data. V.M. drafted the manuscript. All authors read and approved the final manuscript.

The authors have no conflict of interests related to this publication.

This study was carried out in accordance with the recommendations of the Princess Alexandra Hospital, Queensland, Australia. The protocol was approved by the Metro South Health Human Research Ethics Committee. All subjects gave written informed consent in accordance with the Declaration of Helsinki.

The de-identified data used to support the findings of this study are available from the corresponding author at vera.meeusen@health.qld.gov.au upon request.

None of the researchers have a conflict of interest to declare. This work was supported by the Gastroenterology & Hepatology Department of the Princess Alexandra Hospital, Queensland, Australia. No funding was required.

Contributor Information

Vera Meeusen, Email: vera.meeusen@health.qld.gov.au.

Mijin Kim, Email: mijin.kim@health.qld.gov.au.

Marilyn Roque, Email: Marilyn.roque@health.qld.gov.au.

Pal Sivalingam, Email: pal.sivalingam@health.qld.gov.au.

Zaki Hamarneh, Email: zaki.hamarneh@health.qld.gov.au.

Luke Hourigan, Email: luke.hourigan@health.qld.gov.au.

REFERENCES

  1. Afghani E., Akshintala V. S., Khashab M. A., Law J. K., Hutfless S. M., Kim K. J., … Singh V. K. (2014). 5-Fr vs. 3-Fr pancreatic stents for the prevention of post-ERCP pancreatitis in high-risk patients: A systematic review and network meta-analysis. Endoscopy, 46(7), 573–580. doi: 10.1055/s-0034-1365701 [DOI] [PubMed] [Google Scholar]
  2. Alam L., Khan R. S. A., Saeed F., Sher F., & Khan R. Z. A. (2023). Does patient’s position count during endoscopic retrograde cholangio-pancreatography? Left lateral decubitus versus prone position. Pakistan Journal of Medical Sciences, 39(5), 1232–1237. doi: 10.12669/pjms.39.5.6932 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Alcivar-Leon M., Nieto-Orellana I., Jara-Alba M. L., & Marriott-Diaz E. (2017). Efficacy and safety in left lateral decubitus versus prone position for endoscopic retrograde cholangiopancreatography (ERCP). American Journal of Gastroenterology, 112, S445. doi: 10.14309/00000434-201710001-00799 [DOI] [Google Scholar]
  4. American Society of Anesthesiologists. (2018). Practice advisory for the prevention of perioperative peripheral neuropathies 2018: An updated report by the American Society of anesthesiologists task force on prevention of perioperative peripheral neuropathies. Anesthesiology, 128(1), 11–26. doi: 10.1097/ALN.0000000000001937 [DOI] [PubMed] [Google Scholar]
  5. Angsuwatcharakon P., Janjeurmat W., Krisanachinda A., Ridtitid W., Kongkam P., & Rerknimitr R. (2018). The difference in ocular lens equivalent dose to ERCP personnel between prone and left lateral decubitus positions: A prospective randomized study. Endoscopy International Open, 6(8), E969–E974. doi: 10.1055/a-0599-5917 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Association of Perioperative Registered Nurses (AORN). (2022). Positioning the patient. Denver, Colorado: AORN. [Google Scholar]
  7. Chandrasekhara V., Khashab M. A., Muthusamy V. R., Acosta R. D., Agrawal D., Bruining D. H., … DeWitt J. M.; ASGE Standards of Practice Committee. (2017). Adverse events associated with ERCP. Gastrointestinal Endoscopy, 85(1), 32–47. [DOI] [PubMed] [Google Scholar]
  8. Chen H., Doornbos N., Williams K., & Criado E. (2014). Physiologic variations in venous and arterial hemodynamics in response to postural changes at the thoracic outlet in normal volunteers. Annals of Vascular Surgery, 28(7), 1583–1588. doi: 10.1016/j.avsg.2014.05.003 [DOI] [PubMed] [Google Scholar]
  9. Chen P. H., Tung C. F., Peng Y. C., Yeh H. Z., Chang C. S., & Chen C. C. (2020). Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study. BMC Gastroenterology, 20(1), 310. doi: 10.1186/s12876-020-01455-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Delmore B. A. & Ayello E. A. (2017). CE: pressure injuries caused by medical devices and other objects: A clinical update. The American Journal of Nursing, 117(12), 36–45. doi: 10.1097/01.NAJ.0000527460.93222.31 [DOI] [PubMed] [Google Scholar]
  11. Ferreira L. E. & Baron T. H. (2008). Comparison of safety and efficacy of ERCP performed with the patient in supine and prone positions. Gastrointestinal Endoscopy, 67(7), 1037–1043. doi: 10.1016/j.gie.2007.10.029 [DOI] [PubMed] [Google Scholar]
  12. Freeman M. L. (2012). Complications of endoscopic retrograde cholangiopancreatography. Techniques in Gastrointestinal Endoscopy, 14(3), 148–155. doi: 10.1016/j.tgie.2012.06.001 [DOI] [PubMed] [Google Scholar]
  13. Froehlich F. (2006). Patient position during ERCP: Prone versus supine. What about left lateral throughout? Endoscopy, 38(7), 755. doi: 10.1055/s-2006-925247 [DOI] [PubMed] [Google Scholar]
  14. García-Cano J. (2018). Common bile duct cannulation in the left lateral position during ERCP. Saudi Journal of Gastroenterology, 24(1), 67–68. doi: 10.4103/sjg.SJG_456_17 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Haraldsson E., Lundell L., Swahn F., Enochsson L., Löhr J. M., & Arnelo U.; Scandinavian Association for Digestive Endoscopy (SADE) Study Group of Endoscopic Retrograde Cholangio-Pancreaticography. (2017). Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United European Gastroenterology Journal, 5(4), 504–510. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Johnson K. D., Perisetti A., Tharian B., Thandassery R., Jamidar P., Goyal H., & Inamdar S. (2020). Endoscopic retrograde cholangiopancreatography-related complications and their management strategies: A “Scoping” Literature Review. Digestive Diseases and Sciences, 65(2), 361–375. doi: 10.1007/s10620-019-05970-3 [DOI] [PubMed] [Google Scholar]
  17. Mashiana H. S., Jayaraj M., Mohan B. P., Ohning G., & Adler D. G. (2018). Comparison of outcomes for supine vs. prone position ERCP: A systematic review and meta-analysis. Endoscopy International Open, 6(11), E1296–E1301. doi: 10.1055/a-0603-3302 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Maydeo A. & Patil G. K. (2018). ERCP: Does patient position count? Endoscopy International Open, 6(11), E1302–E1303. doi: 10.1055/a-0732-5193 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Meeusen V., Kim N., Elson J., Ma R., Newman F., Bendeich J., & Holtmann G. (2021). Patient positioning guidelines for gastrointestinal endoscopic procedures. Gastroenterology Nursing, 44(3), 185–191. doi: 10.1097/SGA.0000000000000534 [DOI] [PubMed] [Google Scholar]
  20. Meeusen V., Rogue M., & Elson J. (2019). Case report: Pressure injury after prolonged endoscopic intervention. GENCA Journal, 29(2), 12–14. [Google Scholar]
  21. National Health and Medical Research Council, Australian Research Council and Universities Australia (2018. a). Australian Code for the Responsible Conduct of Research 2018. Canberra, Australian Capital Territory (ACT), Australia: Commonwealth of Australia. [Google Scholar]
  22. The National Health and Medical Research Council, the Australian Research Council and Universities Australia (2018. b). National Statement on Ethical Conduct in Human Research 2007 (Updated 2018). Canberra, Australian Capital Territory (ACT), Australia: Commonwealth of Australia. [Google Scholar]
  23. National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA). (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. Westford, Chicago, Illinois: NPIAP. [Google Scholar]
  24. Osagiede O., Bolaños G. A., Cochuyt J., Cruz L. M., Kröner P. T., Lukens F. J., & Corral J. E. (2021). Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: A retrospective study. Annals of Gastroenterology, 34(4), 582–587. doi: 10.20524/aog.2021.0609 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Park T. Y., Choi S. H., Yang Y. J., Shin S. P., Bang C. S., Suk K. T., … Kim D. J. (2017). The efficacy and safety of the left lateral position for endoscopic retrograde cholangiopancreatography. Saudi Journal of Gastroenterology, 23(5), 296–302. doi: 10.4103/sjg.SJG_121_17 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Raymondos K., Panning B., Bachem I., Manns M. P., Piepenbrock S., & Meier P. N. (2002). Evaluation of endoscopic retrograde cholangiopancreatography under conscious sedation and general anesthesia. Endoscopy, 34(9), 721–726. doi: 10.1055/s-2002-33567 [DOI] [PubMed] [Google Scholar]
  27. Sawyer R. J., Richmond M. N., Hickey J. D., & Jarrratt J. A. (2000). Peripheral nerve injuries associated with anaesthesia. Anaesthesia, 55(10), 980–991. doi: 10.1046/j.1365-2044.2000.01614.x [DOI] [PubMed] [Google Scholar]
  28. Schumann R., Natov N. S., Rocuts-Martinez K. A., Finkelman M. D., Phan T. V., Hegde S. R., & Knapp R. M. (2016). High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. World Journal of Gastroenterology, 22(47), 10398–10405. doi: 10.3748/wjg.v22.i47.10398 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Swan M. P., Alexander S., Moss A., Williams S. J., Ruppin D., Hope R., & Bourke M. J. (2013). Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation. Clinical Gastroenterology and Hepatology, 11(4), 430–436.e1. doi: 10.1016/j.cgh.2012.12.017 [DOI] [PubMed] [Google Scholar]
  30. Talukdar R. (2016). Complications of ERCP. Best practice & research. Clinical Gastroenterology, 30(5), 793–805. doi: 10.1016/j.bpg.2016.10.007 [DOI] [PubMed] [Google Scholar]
  31. Terruzzi V., Radaelli F., Meucci G., & Minoli G. (2005). Is the supine position as safe and effective as the prone position for endoscopic retrograde cholangiopancreatography? A prospective randomized study. Endoscopy, 37(12), 1211–1214. doi: 10.1055/s-2005-870511 [DOI] [PubMed] [Google Scholar]
  32. Thaker A. M., Mosko J. D., & Berzin T. M. (2015). Post-endoscopic retrograde cholangiopancreatography pancreatitis. Gastroenterology Report, 3(1), 32–40. doi: 10.1093/gastro/gou083 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Tringali A., Mutignani M., Milano A., Perri V., & Costamagna G. (2008). No difference between supine and prone position for ERCP in conscious sedated patients: A prospective randomized study. Endoscopy, 40(2), 93–97. doi: 10.1055/s-2007-995317 [DOI] [PubMed] [Google Scholar]
  34. Welch M. B., Brummett C. M., Welch T. D., Tremper K. K., Shanks A. M., Guglani P., & Mashour G. A. (2009). Perioperative peripheral nerve injuries: A retrospective study of 380,680 cases during a 10-year period at a single institution. Anesthesiology, 111(3), 490–497. doi: 10.1097/ALN.0b013e3181af61cb [DOI] [PubMed] [Google Scholar]
  35. Williams E. J., Taylor S., Fairclough P., Hamlyn A., Logan R. F., Martin D., … Lombard M.; BSG Audit of ERCP. (2007). Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice. Gut, 56(6), 821–829. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. World Medical Association. (2001). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human. Bulletin of the World Health Organization, 79(4), 373–374. doi: 10.1007/BF03178503 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Yuen V. M., Xia H. F., Chan Y. W., Yan X., & Irwin M. G. (2016). Anesthesiologist-managed sedation for endoscopic retrograde cholangiopancreatography: Experience at the University of Hong Kong Shenzhen Hospital. Techniques in Gastrointestinal Endoscopy, 18(1), 38–41. doi: 10.1016/j.tgie.2016.03.004 [DOI] [Google Scholar]

Articles from Gastroenterology Nursing are provided here courtesy of Wolters Kluwer Health

RESOURCES