S13 Comparison of ERCP Success Rates and Complications in Supine vs Prone Position for Biliary Cannulation: A Systematic Review and Meta-Analysis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a critical procedure for managing biliary and pancreatic disorders. Previous reports showed that patient positioning is known to affect cannulation success rates and complications. While the prone position has been the traditional standard for ERCP due to its favorable orientation for endoscope maneuvering and bile duct access, supine positioning may be necessary in specific instances, for example, in the intensive care unit setting. This meta-analysis aims to compare biliary cannulation success rates and complication rates between supine and prone positions during ERCP. Methods: We conducted a comprehensive literature search using PubMed with the search terms: “(ERCP OR “endoscopic retrograde cholangiopancreatography”) and (prone [Title] OR supine [Title] OR position [Title] OR positioning [Title])” limited to the last 20 years. From 54 initial results, 11 relevant articles were screened. RCT and observational studies comparing ERCP performed in prone vs supine positions were included. Primary outcomes were biliary cannulation success rate and complication rate. We used the DerSimonian-Laird random-effects model to conduct the meta-analyses in RStudio. The I-squared (I²) statistic was calculated to quantify the degree of heterogeneity between the studies. Results: Our analysis included 4 studies with a total of 21,893 patients. The pooled analysis showed that prone positioning had a slightly higher success rate for biliary cannulation but was not statistically significant (RR: 1.02, 95% CI: 0.99-1.06, P = 0.13). Complication rate favored prone positioning, however, was not statistically significant (RR: 0.65, 95% CI: 0.24-1.74, P = 0.25). For the technical success analysis, the I² was 65%, P < 0.032. For the complications analysis, the I² was 96%, P < 0.001. Conclusion: Our meta-analysis highlights that while the prone position should remain the standard for ERCP, the supine position is a reasonable alternative for selected patients, with comparable complication rates and success in biliary cannulation. Circumstances may necessitate supine ERCP, and the decision to perform supine ERCP should be guided by individual patient factors and physician expertise. Further prospective studies are needed to identify subgroups that benefit most from each ERCP position.