Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) requires adequate sedation for successful completion. The sedation type may affect rates of cannulation, success of intended intervention, and utilization of resources. Recent trends have favored the use of general anesthesia (GA) more frequently for advanced endoscopic procedures. We hypothesize that a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or GA will result in similar rates of successful interventions and complications, while offering more favorable utilization of resources compared to performing all ERCPs with GA. This is a prospective study evaluating the success rates, complications, and resource utilization in patients undergoing ERCP in an ambulatory procedure center. The study assessed 502 consecutive ERCPs from January 2017 to July 2017. Indications for GA included chronic opiates, benzodiazepines, or alcohol abuse; severity of patient illness; morbid obesity; complexity or difficulty of intervention as characterized by Modified Schutz Score; prior failed procedure or poor tolerance with MCS, or prior GA use. The outcomes of success of the intended intervention, cannulation rates, complications, total operating room (OR) and procedure time, and recovery time were compared. Of the 502 ERCPs, 366 (72.9%) were performed with MCS vs. 136 (27.1%) performed with GA. Successful intended interventions were completed in 350 / 366 cases with MCS vs. 129 / 136 cases with GA (95.6% versus 94.9% respectively, p=0.712). Cannulation success rates with MCS were 357 / 366 vs. 132 / 136 with GA (97.5% versus 97.1%, p=0.762). Of the 16 / 366 cases with MCS which failed, 9 / 366 (2.5%) were attributed to sedation complications such as hypoxia, hypotension, or patient restlessness preventing the intended intervention. Overall adverse event rates were significantly lower in MCS vs. GA (p=0.04). The rates of post-ERCP pancreatitis were not significantly different between the two groups (p=0.18). Mean procedure time for MCS vs. GA was 17.4 +/- 12.5 minutes versus 24.7 +/- 20.9 minutes (p<0.00001). Mean OR time for MCS vs. GA was 49.1 +/- 18.0 minutes vs. 52.4 +/- 22.5 minutes (p=0.087). Mean recovery time for MCS vs. GA was 82.6 +/- 42.2 minutes vs. 92.1 +/- 40.5 minutes (p=0.024). ERCP can be accomplished with comparable rates of success with MCS compared with GA with use of a selective sedation protocol which accounts for patient and procedure related factors. Further studies to assess the cost benefit with selective sedation would be beneficial.
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