Deeper sedation during ERCP is associated with fewer retained common bile duct stones: a prospective population-based register study

Endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stone (CBDS) removal can be performed under varying levels of sedation. Deeper sedation has been associated with more successful cannulation, but little is known about the effectiveness of ERCP, measured as rate of retained CBDS, depending on the level of sedation. In this observational population-based cohort study data on 121 252 ERCP procedures were retrieved from the Swedish Register for Gallstone Surgery and ERCP (Gallriks). Adjusted odds ratios (OR) for retained CBDS 12 months after CBDS removal were estimated. Retained CBDS was defined as reintervention with ERCP finding a CBDS. General endotracheal anaesthesia (GEA) was associated with 27% lower odds for retained CBDS compared to light endoscopist-directed conscious sedation (EDCS) after adjusting for confounding factors. Adjusted OR for GEA was 0.73 (CI 0.66–0.80), for anaesthetist-directed propofol sedation (monitored anaesthesia care) (ADPS (MAC)) 0.84 (CI 0.76–0.93), and for endoscopist-directed propofol sedation (EDPS) 0.83 (CI 0.72–0.95). Pairwise comparison revealed a 13% (OR 0.87 CI 0.77–0.99) reduction of odds in favour of GEA compared to ADPS (MAC), but no significant difference compared to EDPS. An association was observed between deeper sedation and lower odds of retained CBDS compared to EDCS, with a marginal benefit of GEA over ADPS (MAC). Safety outcomes were not assessed, and findings are subject to unmeasured confounding why no causal conclusion can be made.