Left Lateral Position and Prone Position for Endoscopic Retrograde Cholangiopancreatography
Left Lateral Position and Prone Position for Endoscopic Retrograde Cholangiopancreatography
Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in diagnosis and
 treatment of pancreaticobiliary diseases. Traditionally, ERCP has been performed in the prone
 position. The prone position for ERCP can facilitate selective bile duct cannulation, offer a
 better fluoroscopic image of pancreaticobiliary anatomy, and prevent aspiration of gastric
 contents. However, in cases of difficult in the prone position, ERCP has been performed in
 the left lateral or supine position. Compared with the prone position, left lateral position
 is more comfortable for patients, especially with limitation for cervical movement including
 cervical cord injury, cervical spine operation, parkinson's disease, contracture due to
 cerebral infarction, and allow more easy passage of the scope through the pharynx, and useful
 to secure airway. However, in the left lateral position, it is difficult to obtain
 fluoroscopic image of right hepatic duct and intrahepatic bile duct.

 In cases of severe abdominal pain, severe abdominal distension, large amount of ascites,
 recent abdominal surgery or cervical spine surgery, intra-abdominal catheter insertion,
 severe obesity, it is difficult to position in prone or left lateral, therefore, ERCP may be
 performed in the supine position. In supine position for ERCP, there has been documented
 increased risk of cardiopulmonary adverse event and decreased success rate of selective bile
 duct cannulation.

 There have been reported the efficacy and safety between the prone position and supine
 position for ERCP in several studies. We aimed to evaluate the efficacy and safety between
 the prone position and left lateral position for ERCP in this prospective, randomized study.
Methods

 1. Written informed consent for the endoscopic retrograde cholangiopancreatography is
 obtained from all patients.

 2. Blood culture is performed, and intravenous 3rd generation cephalosporin is administered
 routinely.

 3. Before endoscopic procedure, patients are randomly assigned to left lateral position or
 prone position for the endoscopic retrograde cholangiopancreatography.

 4. Conscious sedation is performed by non-anesthesiologist-assisted method. Intravenous
 midazolam 0.05-0.1 mg/kg and/or intravenous propofol 0.5mg-1mg/kg is administered.
 Analgesics was administered intravenous meperidine 25mg in patients with older than 50
 years and meperidine 50mg in patients with younger than 50 years. To limit duodenal
 peristalsis hyoscine-N-butylbromide is administered intravenously.

 5. All patients are provided oxygen 2liter/minute via nasal prong. Patient's oxygen
 saturation, heart rate, blood pressure and respiration are monitored during procedure.

 6. Selective bile duct cannulation is performed by wire-guided cannulation method. If
 adverse event is occur during endoscopic procedure, it is recorded in the case report
 form as intra-procedural adverse event.

 7. After 4 hours, 24 hours, 2 weeks and 6 weeks of the procedure, white blood cell count,
 hemoglobin, platelet count, total bilirubin, aspartate transaminase, alanine
 transaminase, alkaline phosphatase, gamma glutamyl transaminase, amylase, lipase,
 abdomen X-ray, chest X-ray are performed.

 8. Oral feeding is started with sips of water after 24 hours of endoscopic sphincterotomy
 and/or endoscopic papillary balloon dilation.

 9. Development of adverse event including bleeding, perforation, pancreatitis,
 hyperamylasemia, infection, basket impaction, cardiopulmonary adverse event, mortality
 are recorded according to left lateral position or prone position for the endoscopic
 retrograde cholangiopancreatography.
Inclusion Criteria:

 -  All of followings:

 1. Any of following indications for ERCP

 ① Common bile duct stone

 ② Gallstone pancreatitis

 ③ Obstructive jaundice due to malignancy (ex. Pancreas cancer, bile duct cancer,
 ampulla of Vater cancer)

 ④ Common bile duct invasion metastasis of other organ malignancy (ex.
 Hepatocellular carcinoma with bile duct invasion, metastatic lymphadenopathy with
 bile duct invasion from malignancy other than pancreaticobiliary malignancy)

 ⑤ Benign biliary stricture

 2. Naïve papilla

 3. Aged over 20 years

 Exclusion Criteria:

 -  Any of followings:

 1. History of endoscopic retrograde cholangiopancreatography

 2. Altered gastric and duodenal anatomy due to intra-abdominal surgery (ex. Billroth
 gastrectomy, total gastrectomy)

 3. Patients with severe infection or hemodynamic unstable (ex. septic shock,
 intubation, ventilator, inotropics)

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

 5. Severe neurologic disease

 6. Patients with possible prone position (ex. severe abdominal pain, severe
 abdominal distension, large amount of ascites, recent intra-abdominal surgery,
 neck surgery, intra-abdominal catheter insertion, severe obesity)