Post written by Danny Issa, MD, from UCLA, Los Angeles, California, USA.

This study explores the clinical outcomes of ERCP in the supine versus prone patient position when performed by a trainee. Studies have reported variable outcomes of ERCP in each position. In the United States, the majority of ERCPs are performed in prone positions.

Nevertheless, no data are available on the outcomes from the perspective of an advanced endoscopy trainee (AET) learning both techniques simultaneously. Therefore, this study was designed as a prospective trial at a high-volume center to evaluate the effect of patient position on ERCP outcomes and further examine the learning curve toward competence.

The importance of our study includes its design and the strict parameters assessing ERCP outcomes, limiting interoperator variability between supervising attending. The AET was universally given 5 cannulation attempts each case. Only native papillae were included, and intraprocedural documentation was performed for time intervals, cannulation attempts, difficult cannulations, and interventions.

The study showed no difference in the primary outcome of successful biliary cannulation by AET between supine and prone positions (69% vs 68%, respectively; P = .95). Even after excluding difficult cannulation cases, the rates remained comparable (Fig. 1). The adverse event rate, including post-ERCP pancreatitis (8%), was similar between the groups.

Another significant finding was the reduction in the procedure duration (32 vs 42 minutes, respectively; P = .048) and total room time for patients undergoing supine ERCP. On average, 38 minutes were saved in supine compared with prone cases concerning total room turnover time.

Although studies are needed to validate these findings, these data suggest that the supine position has multilayered benefits that could significantly increase endoscopic unit use.

We then assessed the learning curve by measuring quarterly outcomes throughout the academic year. A significant stepwise increase in the rate of successful cannulation by the AET was seen for both positions. The rate improved from 54% to 90% in supine and 56% to 83% in prone. However, the learning curve toward competence was steeper in supine.

One area that was not discussed in the study is the significance of room ergonomics during ERCP. Endoscopist position and monitor orientation are different in each position, and efforts should be made to ensure room designs are accommodating.

ERCP is one of the most technically demanding endoscopic procedures and requires dedicated training to perform the procedure independently while minimizing the risk of adverse events. Endoscopists need to have knowledge and competence in both ERCP positions, and our study suggests early training in supine and prone ERCP simultaneously for AETs.

AET cannulation rates in supine and prone patient positioning for ERCP throughout the academic year. AET, Advanced endoscopy trainee.

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