Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP)

Abstract

Objectives. Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings. Methods. A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA. Results. A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA ( p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA ( p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively ( p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum. Conclusions. Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance.

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

“…Titrated doses of conscious sedation may be adequate in the majority of these procedures. 169 It is important to note that even grade 1 and grade 2 ERCP and diagnostic EUS can at times be challenging and prolonged. Apart from the expected procedural complexity, the patient's anxiety level, BMI, ASA class, cardiopulmonary comorbidity, medication history and tolerance of previous procedures under sedation need to be considered when deciding whether mild/ moderate sedation is adequate in these patients.…”

Up-to-date literature review and issues of sedation during digestive endoscopy.

“…These procedures usually take longer than conventional ones, requiring deeper sedation and more advanced care to enhance sedation practices and intervention against potential complications. Various studies have been published in this context to evaluate the safety and efficacy of sedation practices and dosages, and to compare the effectiveness of combined versus single-drug administration [113][114][115]. For instance, a previous study showed that the efficacy of ESD for early gastric cancer was comparable between intermittent midazolam injection and continuous propofol infusion [116].…”