New Sedation Findings: ERCP for Bile and Pancreatic Ducts

An international team of expert anesthesiologists and gastroenterologists recently determined that patients undergoing endoscopic retrograde cholangiopancreatography (ERCP)—a procedure that combines upper gastrointestinal endoscopy and X-rays to treat problems of the bile and pancreatic ducts—may be better served by deep sedation without tracheal intubation, compared to receiving general anesthesia with tracheal intubation.

The research group developed evidence-based practical guidelines for clinicians to consider, after assessing the merits and risks of both techniques. The article was published in the British Journal of Anaesthesia.

Each year 600,000 ERCP procedures are performed in the United States. This procedure is time-consuming, resource intensive and can lead to adverse events, including admission to the post-anesthesia care unit. After assessing a variety of complex patient scenarios, the group determined that for short, routine procedures with low complexity, monitored anesthesia care (deep sedation) rather than general anesthesia could lead to faster and better recovery after ERCP. The researchers stress, however, that each institution should base this recommendation on its own resources, expertise and individual patient characteristics.

The below Q&A was completed by Omid Azimaraghi, M.D., research fellow in the department of anesthesiology, and Matthias Eikermann, M.D., the Francis F. Foldes Professor and chair of the department of anesthesiology for Montefiore Health System in Tarrytown, N.Y.

What led you to assess sedation techniques for endoscopic retrograde cholangiopancreatography (ERCP)?

There is currently no standard of care to guide the choice on monitored anesthesia care versus general anesthesia for ERCP to determine which approach produces the best outcome for patients. We conducted a large retrospective analysis and published in the BJA, which favored monitored anesthesia care (Br J Anaesth. 2021 Jan;126(1):191-200.) and from there decided to consult with experts all over the world to create consensus guidelines.

Why is this an important area of investigation?

The number of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed is increasing. In the United States alone, more than 600,000 ERCP procedures are performed annually. General anesthesia versus monitored sedation lead to very different effects on breathing and circulation, which can affect patients’ safety and outcomes. During ERCP, anesthesiologists and gastroenterologists also share the patients’ upper airway, such that a collaborative and consensual approach is needed.

What did you find?

Monitored anesthesia care is the favored anesthesia plan for ERCP for short, routine procedures. General anesthesia can be avoided in most scenarios. However, patients who undergo very long endoscopic procedures that carry a substantial risk of organ perforation or food aspiration should be intubated such that the procedure can be done under general anesthesia.

The consensus guidelines emphasize the value of effective interprofessional communication and also highlight that local culture and knowledge needs to be integrated into the decisions around the anesthesia plan.

How will this impact clinicians?

Monitored anesthesia care should be considered as the favored method of anesthesia in the majority of cases. We encourage gastroenterologists and anesthesiologists to communicate frequently—for example, discuss the procedures in a morning meeting—so that risk/benefit analyses can be conducted for individual patients, and clinicians can consider their experience levels, patients’ comorbidities, and procedural risks.

How will this impact patients?

Patients would spend less time in the endoscopy suite since turnover time is shorter with MAC [monitored anesthesia care]. Also, eliminating tracheal intubation eliminates some predictable signs and symptoms for the patient, such as sore throat and hoarseness.

What are the next steps, if any?

This study will help clinicians reflect on the best way for them to practice anesthesia for ERCP at their institution. This work represents the highest level of evidence currently available that can be taken into account by clinicians as a guideline for clinical decision-making.

To read more on this topic, see the article, “Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography,” published in the British Journal of Anaesthesia.

ASGE Guidelines for ERCP

Every healthcare professional knows that guidelines from trusted industry associations can be invaluable for job performance and patient safety. Such guidelines exist for ERCP, courtesy of the American Society for Gastrointestinal Endoscopy (ASGE) Standards for Practice Committee. According to the ASGE committee members, ERCP has become an invaluable procedure in the diagnosis and management of a variety of pancreaticobiliary disorders since its introduction in 1968.

“The role of ERCP has evolved from a diagnostic to a mainly therapeutic intervention because of improvements in other imaging modalities including magnetic resonance imaging and/or MRCP and EUS,” the committee wrote in a guideline document, “Adverse Events Associated with ERCP.”

“For endoscopists to accurately consider the clinical appropriateness of ERCP, it is important for them to have a thorough understanding of available alternatives and of the potential adverse events associated with the procedure. In addition, they must understand and attempt to follow maneuvers that reduce the risk of adverse events. Early recognition and appropriate management of potential adverse events are critical to reducing morbidity and mortality associated with the procedure.”

The guideline is intended to help endoscopists provide care to patients, but it is not a rule and “should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment,” according to the ASGE Standards for Practice Committee. “Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.”

The document is 44 pages (not including references) and includes background information and in-depth analysis, as well as quick-hit recommendations, such as the following:

1. We recommend that physicians who perform ERCP be facile with procedural techniques that reduce the risk of pancreatitis (i.e., wire-guided cannulation, prophylactic pancreatic duct stenting).
2. We recommend early precut sphincterotomy for difficult biliary cannulation when expertise is available.
3. We recommend pancreatic duct stenting to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk individuals.
4. We recommend administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDS) to reduce the incidence and severity of PEP in high-risk individuals without contraindication.
5. We suggest that rectal indomethacin may reduce the risk and severity of post-ERCP pancreatitis in average-risk individuals.
6. We suggest that there is insufficient evidence that a combination of rectal NSAIDs and pancreatic duct stenting is superior to either technique alone for prevention of post-ERCP pancreatitis in high-risk individuals.
7. We suggest periprocedural intravenous hydration with lactated ringers when feasible to decrease the risk of post-ERCP pancreatitis.
8. We recommend against the routine use of endoscopic papillary large balloon dilation (EPLBD) of an intact sphincter rather than endoscopic sphincterotomy with or without adjunct balloon sphincteroplasty to facilitate biliary stone extraction in patients without coagulopathy because of the increased risk of pancreatitis. If EPLBD alone is used, dilation more than 1 minute is recommended.
9. We recommend that sphincterotomy should be selectively performed in patients considered high risk for bleeding. Routine sphincterotomy should not be offered in high-risk individuals for bleeding when not absolutely indicated.
10. We recommend the use of a microprocessor-controlled generator with mixed current when sphincterotomy is being performed to reduce the risk of post-sphincterotomy bleeding.
11. We recommend that antibiotic prophylaxis be administered before ERCP in patients who have had liver transplantation or when there is a possibility of incomplete biliary drainage. Antibiotics that cover biliary flora such as enteric gram-negative organisms and enterococci should be used and continued after the procedure if biliary drainage is incomplete.
12. We recommend that facilities ensure strict compliance with current manufacturer protocols and U.S. Food and Drug Administration recommendations for duodenoscope reprocessing to limit duodenoscope-related transmission of infections.
13. We suggest that patients with suspected periampullary or instrument-related perforations from ERCP without evidence of peritonitis or systemic inflammatory response syndrome (SIRS) may be managed non-operatively.
14. We suggest that premedication is not necessary to prevent contrast media allergy during ERCP in patients with a prior history of food or intravenous contrast allergies.

To access these guidelines in full, visit www.asge.org.