Impact of Patient Positioning and Endotracheal Intubation During Ercp: Insights From a Large Database

Impact of Patient Positioning and Endotracheal Intubation During Ercp: Insights From a Large Database | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Patient Positioning and Endotracheal Intubation During Ercp: Insights From a Large Database Divyanshoo R Kohli, Nishant Puri, Douglas A Hanes, Jack Brandabur, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7458267/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted 9 You are reading this latest preprint version Abstract Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is conventionally performed in the prone position after intubating the airway. However, ERCP can also be performed in the left lateral and supine positions without endotracheal intubation. We compared procedural metrics and outcomes in patients placed prone, supine, and left lateral during ERCP. Methods In this retrospective multi-center analysis using a large, organization-wide database, patients were categorized as prone, supine, and left lateral based on the positioning for ERCP. Procedural metrics were calculated using contemporaneous electronic health records. All-cause readmission within 7 days and 30 days of ERCP was analyzed. Results The 6510 patients who met selection criteria were categorized as follows: Supine: 3362; left lateral: 2149; and prone: 999. Endotracheal intubation was performed more frequently in supine (90%) and prone (95%) positions than left lateral position (27%; p < 0.01). The time intervals (minutes) for left lateral, prone, and supine positions were: induction time 7.54 ± 4.95, 9.3 ± 6.22, 6.77 ± 3.67; anesthesia ready time 8.98 ± 5.15, 14.13 ± 7.41, 9.41 ± 3.96; ERCP duration 31.71 ± 25.77, 40.99 ± 28.6, 36.49 ± 29.03 and total time in room 54.95 ± 30.26, 72.61 ± 32.76, 62.44 ± 33.06 (p < 0.001 for each measure between three groups) respectively. Regression and variable impact analysis demonstrated that endotracheal intubation was the most significant factor for increased induction time (100%), anesthesia ready time (97%), and duration of ERCP (55%). Adjusted odds of readmission at 7 days were lower in supine patients compared to prone (0.63; 95%CI 0.44,0.91; p = 0.01) Conclusion Supine and left lateral positions improve procedural efficiency primarily due to reduced endotracheal intubation rates, without increasing readmission. ERCP Endotracheal Intubation outcomes prone position WHAT YOU NEED TO KNOW BACKGROUND: ERCP is often performed in prone position after endotracheal intubation but can be done in the supine and left lateral position without universal endotracheal intubation. FINDINGS: ERCP performed in the left lateral or supine position improved procedural metrics and efficiency across various stages of the ERCP, without an increase in adverse events. The improved metrics were mostly due to reduction in need of endotracheal intubation. IMPLICATIONS FOR PATIENT CARE ERCP in the left lateral or supine position is preferable to the more commonly performed prone position. Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a common therapeutic procedure which is traditionally performed after endotracheal intubation of the airway and placing the patient in the prone position ( 1 ). The prone position is favored due to ease of visualization of the major papilla and favorable angle for cannulation of the bile duct. The endotracheal intubation secures the airway, minimizes the risk of aspiration, and facilitates resuscitative maneuvers if required. However, ERCP can also be performed in the left lateral or supine positions without necessarily intubating the airway. Indeed, in some circumstances, ERCP may be more appropriate in the supine or left lateral position due to requirements of mechanical ventilation, morbid obesity, presence of abdominal drains, recent surgery, pregnancy, or need for easier access to the pancreas duct ( 1 , 2 ). The differences in the outcomes of ERCP performed in the supine, left lateral, and prone positions, if any, are unclear. The currently available studies are very few in number and further limited by modest sample sizes and single-center retrospective study designs( 3 ). The results of these studies are often contradictory, with some studies suggesting worse outcomes with supine position( 4 , 5 ) and others demonstrating no difference( 6 , 7 ). Hence, we performed this multicenter analysis that compared procedural metrics and outcomes of ERCP performed in the supine, prone, and left lateral positions across a diverse set of hospital settings. Our primary interest, based upon clinical experience, was to assess whether different patient positions could affect procedure efficiency without changing incidence of adverse outcomes. Methods Study design and selection criteria In this retrospective multi-center analysis using a large, organization-wide database, patients undergoing ERCP from January 1, 2020 through May 31, 2024 at any of the Providence hospitals within Washinton state were identified using relevant Current Procedural Terminology codes( 8 , 9 ). De-identified medical records were accessed using proprietary electronic health records software (Epic®) and relevant data were abstracted. The patients were categorized as prone, supine, and left lateral based on the positioning at the start of the ERCP, when the duodenoscope was advanced into the mouth. This did not include the position of the patient at the time of endotracheal intubation, if performed. Patients with incomplete records, surgically altered foregut anatomy, enteroscopy assisted ERCP, or other concomitant procedures such as Endoscopic ultrasonography were excluded. Patients who underwent intra-operative ERCP during a cholecystectomy were also excluded as were patients undergoing endosonographic or radiological rendezvous biliary access procedures. The primary outcome was duration of ERCP. Secondary outcomes included time needed for pre-procedure evaluation, induction of anesthesia, and incidence of readmission. We also evaluated the relative impact of endotracheal intubation and patient positioning on the efficiency of throughput during ERCP. Definitions The duration of preoperative assessment was calculated from the patient’s entry to the pre-procedure area to being ready for being taken the procedure room for the ERCP. This included time for performing a history and physical exam, obtaining consent and intravenous access, undergoing evaluation by the anesthesia team, and any other appropriate testing. This did not include time spent by the patient waiting to be called for the ERCP. Time for induction of anesthesia was calculated from the time of the patient’s entry into the procedure room till induction of anesthesia. This included time needed for transferring the patient to the fluoroscopy table, positioning the patient, attaching leads, obtaining pre-induction vitals, and administering the initial anesthetic medication. Anesthesia ready time was calculated from the time of entry into the procedure room to being ready for the introduction of the duodenoscope into the mouth. This included the induction time noted above as well as time for administration of any additional medications, endotracheal intubation (if performed), repositioning the patient from supine to prone if necessary, performing time out and getting ready for the endoscopist to start the ERCP. Procedure duration was calculated from the initial introduction of the duodenoscope into the mouth to its removal after completion of the ERCP. This included time needed for all interventions performed during the ERCP and administration of any intra-procedural medications. Total time in procedure room was calculated from the entry of the patient into the procedure room till their exit to the recovery area after completion of ERCP. This included the anesthesia ready time, procedure duration, and time needed for assessment of the patient after completion of the ERCP, extubation if needed, and transferring patient from the fluoroscopy table to the bed or gurney. All cause hospitalization was defined by any unanticipated hospitalization or visit to the urgent care or emergency room within 7 days and 30 days of the ERCP. This was calculated only for outpatient ERCP procedures and excluded pre-scheduled visits to hospital-based outpatient practices, post-procedure clinic visits to the gastroenterologist or surgeon or preplanned invasive interventions or surgeries such as elective cholecystectomy after ERCP for choledocholithiasis. All cause hospitalization encompassed common adverse events associated with ERCP including post-ERCP pancreatitis, bleeding, perforation, or cholangitis( 10 ). Statistical analysis Descriptive statistics are presented as mean ± standard deviation for continuous variables and count (%) for categorical variables. Preliminary comparisons of outcomes between position groups used one-way ANOVA or chi-squared analyses, as appropriate. Multivariate logistic regression analysis was used for calculating adjusted ratios and variable importance statistics. Timing outcomes were log-transformed and analyzed using mixed effects models with a random intercept for endoscopist (in the case of procedure times) or facility (for pre-operative, anesthesia, and post-operative times). The initial position was used as the main factor. Additional analysis was performed after adjusting for endotracheal intubation, the treating physician/facility, number of interventions during the ERCP, and indication for ERCP to better understand impact of intubation and possible mediation of position effects through different rates of intubation. Estimates of group effect are presented as percent changes (with 95% confidence interval) of the untransformed variable from the reference group (prone position). Association of procedure position with unanticipated hospitalization or urgent care was assessed using a multivariable mixed effects model adjusted for patient age, indication, number of procedures performed in surgery, treating facility/physician, urgency of care (elective vs emergent/urgent), body mass index, and type of anesthesia administered for the ERCP. A p-value of < 0.05 was considered statistically significant in all analyses. Statistical analysis was performed using R version 4.3.2 with the package lme4 used for mixed model analysis and variable importance computed using the package glmm.hp. The study was approved by the institutional review board at Providence Sacred Heart Medical Center. Results A total of 6,510 patients across 11 hospitals in Washington state who underwent ERCP by 19 endoscopists met selection criteria, and were categorized into left lateral (N = 2149), prone (N = 999), and supine (N = 3362) subgroups based on the initial position of the patient (Table 1 ). Most of the patients underwent elective ERCP as outpatients. The most common indication for ERCP was biliary stone disease (Table 2 ) and the most common type of procedure was ERCP with stone removal (Table 3 ). Overall, endotracheal intubation was performed in 4567 (70%) patients. However, endotracheal intubation was performed more frequently in prone (937/999, 94%) and supine (3036/3362, 90%) vs left lateral (585/2149, 27%; P < 0.01) positions (Table 1 ). Unadjusted analysis Unadjusted time from patient entry to the procedure room till induction of anesthesia was 7.54 ± 4.95, 9.3 ± 6.22, 6.77 ± 3.67 minutes for left lateral, prone, and supine positions respectively (P < 0.001, Table 4 ). Similarly, the time from entry into the procedure room to being ready for the ERCP was 8.98 ± 5.15, 14.13 ± 7.41, and 9.41 ± 3.96 minutes for left lateral, prone, and supine positions respectively (P < 0.001). The duration of the ERCP and total time in the procedure room for left lateral, prone, and supine positions was 31.71 ± 25.77, 40.99 ± 28.6, 36.49 ± 29.03 and 54.95 ± 30.26, 72.61 ± 32.76, 62.44 ± 33.06 (P < 0.001 for each) minutes, respectively. Mean time needed for exit from the procedure room after completion of the ERCP was also greater in patients treated in the prone position (Table 4 ). Regression analysis Mixed effects regression analyses were performed by adjusting for position alone as well as position along with endotracheal intubation (Table 5 ). After adjusting for number of interventions performed during ERCP, there were significant reductions in time needed for pre-procedure assessment, time in room to anesthesia ready, total time in procedure room, and post-procedure time to room exit for left lateral position. After further adjusting for endotracheal intubation, several time metrics showed significant improvements (Table 5 ). Supine positioning was associated with shorter pre-procedure assessment times compared to both left lateral and prone positions. Post-procedure room exit times were also reduced in the supine position compared to prone and left lateral position, as well as in the left lateral position compared to prone. Total procedure time was shorter in both supine and prone positions relative to left lateral, while total time in the procedure room was reduced in the supine position compared to both others, and in the prone position compared to left lateral (Table 5 ). Variable importance analysis The combined results demonstrated a strong mediation by endotracheal intubation, with increased efficiency in the left lateral position often completely explained by reduced rates of intubation. Subsequent variable importance analysis also demonstrated an outsized impact of endotracheal intubation on time needed to complete various components of the overall procedure, especially for induction of anesthesia, getting ready for the ERCP, and exiting the room after completion of the procedure. The duration of the ERCP was impacted by the number of interventions performed during ERCP (45%) as well as endotracheal intubation (55%). Notably, the position of the patient did not have a significant impact on the duration of the actual endoscopic procedure. Unanticipated all-cause hospitalization In unadjusted analysis, the incidence of all-cause unanticipated ER or hospital visits at 7 days and 30 days from the ERCP was the highest in the prone position compared to the supine and left lateral positions (Table 6 ). After adjusting for clinical and procedural factors as well as random facility effects, only the difference in 7-day return visits was significantly lower in supine patients compared to prone (adjusted Odds ratio = 0.63; 95% CI = (0.44, 0.91); p = .01). Adjusted differences in 30-day hospitalization were not significant between any groups. Discussion ERCP remains a frequently performed therapeutic intervention for managing diverse pancreato-biliary conditions( 11 – 14 ). This study assessed the overlapping impact of patient position as well as endotracheal intubation in terms of procedure efficiency and risk of adverse outcomes. To our knowledge, this is the largest study of its type to date. The study suggests that ERCP procedures performed in the left lateral or supine positions can reduce the need for endotracheal intubation and improve procedural metrics without an increase in the risk of hospitalization. Prone position is often the default position adopted by endoscopists due to its perceived benefits of improved ampullary position, better alignment of the bile duct, superior delineation of the pancreato-biliary anatomy and greater familiarity. There is a general reluctance to perform ERCP in the supine or left lateral position even among expert endoscopists( 1 ). Further, i nterpretation of the fluoroscopic images in the left lateral position can be challenging since the pancreatic and biliary wires often overlap in their initial course close to the ampulla. The filling of the right intrahepatic ducts may also be suboptimal in the left lateral position due to gravitational forces( 15 ) but this is easily remedied by injecting more contrast during balloon occlusion cholangiography. This study reports that ERCP in the left lateral and supine positions can be used for all types of pancreato-biliary interventions. Due to the alignment of the pancreas duct with the left lateral and supine positions, there is a higher likelihood of inadvertent PD cannulation and consequent post-ERCP pancreatitis with the left lateral and supine positions( 16 ). However, cannulation of the pancreas duct can also facilitate its stenting, thus mitigating the risk of post-ERCP pancreatitis( 17 ). Indeed, a subgroup analysis by Mashiana et al, showed that supine and prone positions had similar rates of cardiopulmonary adverse events and post-ERCP pancreatitis( 3 ). Similarly, two prospective studies from Asia comparing the outcomes of left lateral and prone ERCP reported higher incidence of unintentional cannulation of the pancreatic duct but did not demonstrate an increase in the incidence of post ERCP pancreatitis( 7 , 18 ) which could be due to maneuvers such as use of indomethacin suppository or pancreatic ductal stenting. Our study did not specifically assess rates of pancreatic duct cannulation but reports comparable incidence of post-ERCP readmission. A prospective study by Issa et al, also demonstrated shorter procedure time and room turnover time with comparable cannulation rate for supine relative to prone ERCP procedures. However, this study was limited by modest sample size as there were only 17 patients placed in the prone position, and it did not address the underlying reasons for the shorter procedure time( 19 ). Our study demonstrates that increased efficiency with left lateral and supine positions occurs during the pre-procedure, intra-procedure as well as post-procedure portions of the ERCP. The prone position for the ERCP typically requires initial placement in the supine position, followed by endotracheal intubation, and finally turning the patient 180º to be positioned prone. After the completion of the ERCP, all these steps need to be repeated in the reverse order. All these additional interventions require time and additionally entail the risk of dislodgement of chest leads, endotracheal tube, or the intravenous access. Further, turning obese patients by 180º for ERCP in the prone position provides additional risks of significant ergonomic injury to healthcare personnel( 20 ). ERCP with the patient in the left lateral or supine position may be more comfortable for the patient, eases transfer to and from the fluoroscopy table to the gurney, and allows for better control of the airway and resuscitation maneuvers while also avoiding ergonomic injury to medical personnel ( 19 ). Indeed, the recent consensus guideline created by an international group of expert anesthesiologists and gastroenterologists favors the use of monitored anesthesia care without endotracheal intubation and restricts the use of general anesthesia with endotracheal intubation in select patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity( 21 ). The results of this study provide data to support these recommendations. Comparative data analyzing the outcomes of ERCP in the supine, prone, and left lateral position are lacking and typically restricted to single-center studies of modest sample sizes. A recent systematic review and meta-analysis found only 6 studies of which 3 were limited to abstracts, including one abstract with the largest number of patients. The analysis was limited by publication bias, substantial heterogeneity in the source studies, and few patients in the supine position( 3 ). Tringali and colleagues performed a study of 120 patients and found no difference in the outcomes of ERCP performed in the supine or prone position( 6 ). Terruzzi and colleagues on the other hand performed a small study of 17 patients in each position and demonstrated failure of biliary cannulation in 29% of patients and a higher incidence of cardiopulmonary adverse events in the supine position ( 4 ). Similarly, a retrospective study using the Clinical Outcomes Research Initiative database reported shorter procedure times and comparable fluoroscopy time with the supine position compared to the prone position ( 2 ). Other endoscopists have also reported comparable rates of biliary access with left lateral and prone positions( 15 ). This study is strengthened by its large sample size and ability to analyze multiple confounding variables such as the frequency of endotracheal intubation, position of the patient, indication and urgency of the ERCP, and hospital and physician specific variables. The utilization of a large database helps in overcoming limitations of sample size and facilitates the performance of analysis with appropriate statistical power( 8 , 9 , 22 , 23 ). The study also assesses diverse experiences of multiple endoscopists working in varied hospital settings of different size thus increasing the generalizability of the findings. The study is limited by its retrospective study design and lack of procedure-specific details such as cannulation rates or fluoroscopy time. Comparisons of procedural metrics in different positions are complicated by the strong confounding with intubation. The choice of position is highly associated with the surgeon and/or facility, raising the possibility of residual confounding by other provider effects. The number of patients in the prone position were fewer than those in the supine and left lateral positions. Finally, adverse events have not been categorized into cardiopulmonary/anesthesia related versus those secondary to the procedure itself such as bleeding or post ERCP pancreatitis. However, the incidence of post-ERCP unplanned hospitalization serves as an appropriate surrogate for common adverse events associated with ERCP. This study suggests that ERCP in the left lateral or supine position is time efficient, reduces need for universal endotracheal intubation, without increasing the risk of post-ERCP hospitalization. At one tertiary care high-volume referral center included within our network, all ERCP procedures are performed in the left lateral position and endotracheal intubation is performed solely at the discretion of the anesthesiologist based on the patient’s clinical status. We posit that the decision to perform endotracheal intubation should be decided solely on the needs of the patient rather than the position of the patient during ERCP. These data demonstrate that endoscopists can perform ERCP in the left lateral or supine position without universal endotracheal intubation the patients and placing them in the prone position. Large prospective multi-center studies are needed to confirm the findings of this study. Table 1 Demographics and patient characteristics who underwent Endoscopic retrograde cholangiopancreatography (ERCP) All (n = 6510) Left lateral (N = 2149) Prone (N = 999) Supine (N = 3362) P-value Demographics Age (years) 60.28 ± 17.7 60.2 ± 18 61.37 ± 18.3 60 ± 17.3 0.09 Sex Female 3459 (53%) 1119 (52%) 539 (54%) 1801 (54%) 0.47 Male 3051 (47%) 1030 (48%) 460 (46%) 1561 (46%) Race White 4976 (76%) 1765 (82%) 815 (82%) 2396 (71%) < 0.01 Asian 451 (7%) 60 (3%) 30 (3%) 461 (11%) Black 192 (3%) 20 (1%) 10 (1%) 162(5%) Body mass index (Kg/m 2 ) 28.15 ± 6.8 28.25 ± 6.7 29.12 ± 6.9 27.82 ± 6.8 < 0.01 Body surface area (m 2 ) 1.94 ± 0.3 1.95 ± 0.3 1.96 ± 0.28 1.92 ± 0.3 < 0.01 Location Inpatient 1031 (16%) 270 (13%) 175 (18%) 586 (17%) < 0.01 Outpatient 5479 (84%) 1879 (87%) 824 (82%) 2776 (83%) Urgency Elective 4921 (76%) 1487 (69%) 824 (82%) 2610 (78%) < 0.01 Urgent or emergent 1589 (24%) 662 (31%) 175 (18%) 752 (22%) Anesthesia type General anesthesia 5158 (79%) 1096 (51%) 937 (94%) 3125 (93%) < 0.01 Total Intra-venous Anesthesia (TIVA) 715 (11%) 532 (25%) 42 (4%) 141 (4%) Monitored anesthesia care 637 (10%) 521 (24%) 20 (2%) 96 (3%) Airway Intubated 4567 (70%) 585 (27%) 946 (95%) 3036 (90%) < 0.01 Not intubated 1943 (30%) 1564 (73%) 53 (5%) 326 (10%) All entries are either mean +/- SD or count (column %). p-values are calculated using either one-way ANOVA (continuous variables) or chi-squared tests of proportions (categorical variables). Table 2 Indications for Endoscopic retrograde cholangiopancreatography (ERCP) Indication All (n = 6510) Left lateral (N = 2149) Prone (N = 999) Supine (N = 3362) P-value Biliary disorders 4977 (76.45%) 1666 (77.52%) 865 (86.59%) 2446 (72.75%) < 0.001 Biliary lithiasis 2375 787 525 1063 Biliary pancreatitis 59 16 6 37 Cholangitis 257 80 34 143 Primary sclerosing cholangitis 163 75 29 59 Biliary stricture 1314 398 151 765 Bile leak 52 17 22 13 Complication of liver transplant 36 19 1 16 Adjustment of prosthesis 71 30 6 35 Other biliary disorders 599 217 86 296 Pancreatic disorders 992 (15.24%) 309 (14.38%) 59 (5.91%) 624 (18.56%) 0.001 Acute pancreatitis 244 57 10 177 Chronic pancreatitis 684 234 47 403 Pancreas duct leak / disorders 14 9 0 5 Malignant disorders 345 (5.3%) 97 (4.51%) 45 (4.5%) 203 (6.04%) NS Cholangiocarcinoma 119 32 12 75 Pancreas malignancy 222 65 31 126 Miscellaneous or unclear 164 (2.52%) 58 (2.7%) 29 (2.9%) 77 (2.29%) NS Sphincter of Oddi dysfunction 28 19 1 8 Ampullary disorders 32 (0.49%) 19 (0.88%) 1 (0.1%) 12 (0.36%) NS Ampullary adenoma 32 19 1 12 Table 3 Endoscopic retrograde cholangiopancreatography (ERCP) procedures performed ERCP Procedure CPT code All (n = 6510) Left lateral (N = 2149) Prone (N = 999) Supine (N = 3362) P-value ERCP Diagnostic 43260 170 (2.61%) 71 (3.3%) 24 (2.4%) 75 (2.23%) 0.046 ERCP with biopsy 43261 512 (7.86%) 140 (6.51%) 78 (7.81%) 294 (8.74%) 0.008 ERCP with sphincterotomy 43262 1287 (19.77%) 442 (20.57%) 311 (31.13%) 534 (15.88%) < 0.001 ERCP with manometry 43263 0 0 0 0 ERCP with stone removal 43264 3843 (59.03%) 1147 (53.37%) 583 (58.36%) 2113 (62.85%) < 0.001 ERCP with lithotripsy 43265 136 (2.09%) 39 (1.81%) 36 (3.6%) 61 (1.81%) 0.001 Cholangioscopy or pancreatoscopy (in conjunction with ERCP) 43273 212 (3.26%) 72 (3.35%) 53 (5.31%) 87 (2.59%) < 0.001 ERCP with stent placement 43274 1774 (27.25%) 660 (30.71%) 203 (20.32%) 911 (27.1%) < 0.001 ERCP with removal of stent 43275 1295 (19.89%) 493 (22.94%) 226 (22.62%) 576 (17.13%) < 0.001 ERCP with stent exchange 43276 1719 (26.41%) 421 (19.59%) 182 (18.22%) 1116 (33.19%) < 0.001 ERCP with balloon dilation 43277 289 (4.44%) 106 (4.93%) 37 (3.7%) 146 (4.34%) 0.272 ERCP with ablation 43278 72 (1.11%) 30 (1.4%) 3 (0.3%) 39 (1.16%) 0.026 All n represents number of patients in the column who received at least one intervention of the type indicated in the row. p-values for chi-squared analysis. Table 4 Unadjusted time intervals in minutes (mean ± Standard Deviation) during Endoscopic retrograde cholangiopancreatography (ERCP) in patients placed in different positions Time interval (minutes; mean ± SD) All (n = 6510) Left lateral (N = 2149) Prone (N = 999) Supine (N = 3362) P-value Pre-procedure Preoperative assessment 32.56 ± 18.4 32.24 ± 15.83 36.38 ± 21.54 31.69 ± 18.79 < 0.001 Induction of anesthesia 7.44 ± 4.69 7.54 ± 4.95 9.3 ± 6.22 6.77 ± 3.67 < 0.001 Entry in to procedure room to being ready for ERCP 9.81 ± 4.94 8.98 ± 5.15 14.13 ± 7.41 9.41 ± 3.96 < 0.001 Intra-procedure Duration of ERCP 35.56 ± 28.06 31.71 ± 25.77 40.99 ± 28.6 36.49 ± 29.03 < 0.001 Total time in procedure room 61.53 ± 32.63 54.95 ± 30.26 72.61 ± 32.76 62.44 ± 33.06 < 0.001 Post procedure Completion of ERCP to exit from procedure room 10.77 ± 5.58 10.09 ± 5.16 11.79 ± 6.39 10.89 ± 5.52 < 0.001 Table 6 Incidence of unanticipated emergency room or hospital visit after Endoscopic retrograde cholangiopancreatography (ERCP). Adjusted odds ratio (aOR) using prone position as reference in model adjusted for age, indication, number of surgical procedures, BMI, urgency of procedure, and type of anesthesia administered. Data presented as odds ratio (95% confidence interval; P-value) Hospitalization All (n = 5479) Left lateral (n = 1879) Prone (n = 824) Supine (n = 2776) Unadjusted P-value Within 7 days 253 (4.62%) 95 (5.06%) 49 (5.95%) 109 (3.93%) 0.031 aOR 0.82(0.55–1.24; 0.35) Reference 0.63* (0.44, 0.91; p = 0.01) - Within 30 days 748 (13.6%) 269 (14.3%) 134 (16.26%) 345 (12.43%) 0.01 aOR 0.88(0.64,1.21; 0.45) Reference 0.83 (0.58, 1.8; 0.29) - Abbreviations ERCP: Endoscopic retrograde cholangiopancreatography, ANOVA: Analysis of variance Declarations Acknowledgements The authors gratefully acknowledge the assistance of Nora Mertens, Kendra Fledderman, Rebecca Hart, and Alicia Graves in performing this study. author contribution: DRK: Data analysis, initial draft, and revision of manuscript; DAH: statistical analysis; NP, JB, WS: procedures, revision of manuscript Conflict of interest : None FINANCIAL DISCLOSURE : DRK: Research support, equipment loan from Fujifilm for unrelated project All other authors: None References Wilcox CM. 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Tringali A, Mutignani M, Milano A, Perri V, Costamagna G. No difference between supine and prone position for ERCP in conscious sedated patients: a prospective randomized study. Endoscopy. 2008 Feb;40(2):93–7. Alam L, Khan RSA, Saeed F, Sher F, Khan RZA. Does patient’s position count during Endoscopic Retrograde Cholangio-pancreatography? Left lateral decubitus versus prone position. Pak J Med Sci. 2023;39(5):1232–7. Kohli DR, Kennedy KF, Desai M, Sharma P. Comparative Safety of Endoscopic vs Radiological Gastrostomy Tube Placement: Outcomes From a Large, Nationwide Veterans Affairs Database. Am J Gastroenterol. 2021 Sep 10; Kohli DR, Kennedy KF, Desai M, Sharma P. Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment. Gastrointest Endosc. 2020 Sep 12; ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017 Jan;85(1):32–47. Fujii-Lau LL, Thosani NC, Al-Haddad M, Acoba J, Wray CJ, Zvavanjanja R, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: summary and recommendations. Gastrointest Endosc. 2023 Nov;98(5):685–93. Kohli DR, Amateau SK, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, et al. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: summary and recommendations. Gastrointest Endosc. 2023 Apr;97(4):607–14. Sachdev A, Kashyap JR, D’Cruz S, Kohli DR, Singh R, Singh K. Safety and efficacy of therapeutic endoscopic interventions in the management of biliary leak. Indian J Gastroenterol. 2012 Sep;31(5):253–7. ASGE Standards of Practice Committee, Sheth SG, Machicado JD, Chalhoub JM, Forsmark C, Zyromski N, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: summary and recommendations. Gastrointest Endosc. 2024 Oct;100(4):584–94. Froehlich F. Patient position during ERCP: prone versus supine. What about left lateral throughout? Endoscopy. 2006 Jul;38(7):755; author reply 755. Varma P, Ket S, Paul E, Barnes M, Devonshire DA, Croagh D, et al. Does ERCP position matter? A randomized controlled trial comparing efficacy and complications of left lateral versus prone position (POSITION study). Endosc Int Open. 2022 Apr;10(4):E403–12. Buxbaum JL, Freeman M, Amateau SK, Chalhoub JM, Coelho-Prabhu N, Desai M, et al. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc. 2023 Feb;97(2):153–62. Park TY, Choi SH, Yang YJ, Shin SP, Bang CS, Suk KT, et al. The efficacy and safety of the left lateral position for endoscopic retrograde cholangiopancreatography. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc. 2017;23(5):296–302. Issa D, Sharaiha RZ, Abdelfattah T, Htway Z, Tabibian JH, Thiruvengadam S, et al. Clinical outcomes and learning curve for ERCP during advanced endoscopy training: a comparison of supine versus prone positioning. Gastrointest Endosc. 2023 Oct;98(4):629-633.e1. Pawa S, Kwon RS, Fishman DS, Thosani NC, Shergill A, Grover SC, et al. American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations. Gastrointest Endosc. 2023 Oct;98(4):482–91. Azimaraghi O, Bilal M, Amornyotin S, Arain M, Behrends M, Berzin TM, et al. Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography. Br J Anaesth. 2023 Jun;130(6):763–72. Kohli DR, Desai M, Kennedy KF, Parasa S, Sharma P. Cholecystectomy for Biliary Pancreatitis Is Often Not Performed During Index Hospitalization and Is Associated With Worse Outcomes. Clin Gastroenterol Hepatol. 2020 Dec 8; Kohli DR, Desai MV, Kennedy KF, Pandya P, Sharma P. Patients with post-transplant biliary strictures have significantly higher rates of liver transplant failure and rejection: A nationwide inpatient analysis. J Gastroenterol Hepatol. 2020 Dec 29; Table 5 Table 5 is available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7458267","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":510471820,"identity":"bc981ef2-dbb6-4695-8b32-9ba3c1557e93","order_by":0,"name":"Divyanshoo R Kohli","email":"data:image/png;base64,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","orcid":"","institution":"Pancreas and Liver clinic, Providence Sacred Heart Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Divyanshoo","middleName":"R","lastName":"Kohli","suffix":""},{"id":510471821,"identity":"2a84f4e2-da40-490b-9bf3-0d5a2639b63c","order_by":1,"name":"Nishant Puri","email":"","orcid":"","institution":"Pancreas and Liver clinic, Providence Sacred Heart Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nishant","middleName":"","lastName":"Puri","suffix":""},{"id":510471822,"identity":"43c8509a-6aa9-4081-933e-94daca58b703","order_by":2,"name":"Douglas A Hanes","email":"","orcid":"","institution":"Providence Portland Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Douglas","middleName":"A","lastName":"Hanes","suffix":""},{"id":510471823,"identity":"1af1339b-4013-4793-8405-337920965ff1","order_by":3,"name":"Jack Brandabur","email":"","orcid":"","institution":"Prosser Memorial Health","correspondingAuthor":false,"prefix":"","firstName":"Jack","middleName":"","lastName":"Brandabur","suffix":""},{"id":510471824,"identity":"4ac6d1e8-9046-4db7-902b-a87b352096e6","order_by":4,"name":"Wichit Srikureja","email":"","orcid":"","institution":"Pancreas and Liver clinic, Providence Sacred Heart Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Wichit","middleName":"","lastName":"Srikureja","suffix":""}],"badges":[],"createdAt":"2025-08-26 03:38:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7458267/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7458267/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10620-025-09548-0","type":"published","date":"2025-11-25T15:58:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97178544,"identity":"6597b2a7-fb74-44f7-a7b5-28b99918aa28","added_by":"auto","created_at":"2025-12-01 16:10:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":934282,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7458267/v1/a4bf0875-0e0b-410b-9d60-6e5564b70f47.pdf"},{"id":90919782,"identity":"1cc410cd-ea53-4b5f-8e2a-435f041ad637","added_by":"auto","created_at":"2025-09-09 14:40:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17078,"visible":true,"origin":"","legend":"","description":"","filename":"Table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-7458267/v1/1f4255459784ec57586a391a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImpact of Patient Positioning and Endotracheal Intubation During Ercp: Insights From a Large Database\u003c/p\u003e","fulltext":[{"header":"WHAT YOU NEED TO KNOW","content":"\u003cp\u003eBACKGROUND: \u003c/p\u003e\n\u003cp\u003eERCP is often performed in prone position after endotracheal intubation but can be done in the supine and left lateral position without universal endotracheal intubation.\u003c/p\u003e\n\n\u003cp\u003eFINDINGS: \u003c/p\u003e\n\u003cp\u003eERCP performed in the left lateral or supine position improved procedural metrics and efficiency across various stages of the ERCP, without an increase in adverse events. The improved metrics were mostly due to reduction in need of endotracheal intubation. \u003c/p\u003e\n\n\u003cp\u003eIMPLICATIONS FOR PATIENT CARE \u003c/p\u003e\n\u003cp\u003eERCP in the left lateral or supine position is preferable to the more commonly performed prone position.\u003c/p\u003e\n\n"},{"header":"Introduction","content":"\u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) is a common therapeutic procedure which is traditionally performed after endotracheal intubation of the airway and placing the patient in the prone position (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The prone position is favored due to ease of visualization of the major papilla and favorable angle for cannulation of the bile duct. The endotracheal intubation secures the airway, minimizes the risk of aspiration, and facilitates resuscitative maneuvers if required. However, ERCP can also be performed in the left lateral or supine positions without necessarily intubating the airway. Indeed, in some circumstances, ERCP may be more appropriate in the supine or left lateral position due to requirements of mechanical ventilation, morbid obesity, presence of abdominal drains, recent surgery, pregnancy, or need for easier access to the pancreas duct (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe differences in the outcomes of ERCP performed in the supine, left lateral, and prone positions, if any, are unclear. The currently available studies are very few in number and further limited by modest sample sizes and single-center retrospective study designs(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The results of these studies are often contradictory, with some studies suggesting worse outcomes with supine position(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and others demonstrating no difference(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHence, we performed this multicenter analysis that compared procedural metrics and outcomes of ERCP performed in the supine, prone, and left lateral positions across a diverse set of hospital settings. Our primary interest, based upon clinical experience, was to assess whether different patient positions could affect procedure efficiency without changing incidence of adverse outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and selection criteria\u003c/h2\u003e\u003cp\u003eIn this retrospective multi-center analysis using a large, organization-wide database, patients undergoing ERCP from January 1, 2020 through May 31, 2024 at any of the Providence hospitals within Washinton state were identified using relevant Current Procedural Terminology codes(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). De-identified medical records were accessed using proprietary electronic health records software (Epic\u0026reg;) and relevant data were abstracted. The patients were categorized as prone, supine, and left lateral based on the positioning at the start of the ERCP, when the duodenoscope was advanced into the mouth. This did not include the position of the patient at the time of endotracheal intubation, if performed.\u003c/p\u003e\u003cp\u003ePatients with incomplete records, surgically altered foregut anatomy, enteroscopy assisted ERCP, or other concomitant procedures such as Endoscopic ultrasonography were excluded. Patients who underwent intra-operative ERCP during a cholecystectomy were also excluded as were patients undergoing endosonographic or radiological rendezvous biliary access procedures.\u003c/p\u003e\u003cp\u003eThe primary outcome was duration of ERCP. Secondary outcomes included time needed for pre-procedure evaluation, induction of anesthesia, and incidence of readmission. We also evaluated the relative impact of endotracheal intubation and patient positioning on the efficiency of throughput during ERCP.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDefinitions\u003c/h3\u003e\n\u003cp\u003eThe duration of preoperative assessment was calculated from the patient\u0026rsquo;s entry to the pre-procedure area to being ready for being taken the procedure room for the ERCP. This included time for performing a history and physical exam, obtaining consent and intravenous access, undergoing evaluation by the anesthesia team, and any other appropriate testing. This did not include time spent by the patient waiting to be called for the ERCP.\u003c/p\u003e\u003cp\u003eTime for induction of anesthesia was calculated from the time of the patient\u0026rsquo;s entry into the procedure room till induction of anesthesia. This included time needed for transferring the patient to the fluoroscopy table, positioning the patient, attaching leads, obtaining pre-induction vitals, and administering the initial anesthetic medication.\u003c/p\u003e\u003cp\u003eAnesthesia ready time was calculated from the time of entry into the procedure room to being ready for the introduction of the duodenoscope into the mouth. This included the induction time noted above as well as time for administration of any additional medications, endotracheal intubation (if performed), repositioning the patient from supine to prone if necessary, performing time out and getting ready for the endoscopist to start the ERCP.\u003c/p\u003e\u003cp\u003eProcedure duration was calculated from the initial introduction of the duodenoscope into the mouth to its removal after completion of the ERCP. This included time needed for all interventions performed during the ERCP and administration of any intra-procedural medications.\u003c/p\u003e\u003cp\u003eTotal time in procedure room was calculated from the entry of the patient into the procedure room till their exit to the recovery area after completion of ERCP. This included the anesthesia ready time, procedure duration, and time needed for assessment of the patient after completion of the ERCP, extubation if needed, and transferring patient from the fluoroscopy table to the bed or gurney.\u003c/p\u003e\u003cp\u003eAll cause hospitalization was defined by any unanticipated hospitalization or visit to the urgent care or emergency room within 7 days and 30 days of the ERCP. This was calculated only for outpatient ERCP procedures and excluded pre-scheduled visits to hospital-based outpatient practices, post-procedure clinic visits to the gastroenterologist or surgeon or preplanned invasive interventions or surgeries such as elective cholecystectomy after ERCP for choledocholithiasis. All cause hospitalization encompassed common adverse events associated with ERCP including post-ERCP pancreatitis, bleeding, perforation, or cholangitis(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables and count (%) for categorical variables. Preliminary comparisons of outcomes between position groups used one-way ANOVA or chi-squared analyses, as appropriate. Multivariate logistic regression analysis was used for calculating adjusted ratios and variable importance statistics. Timing outcomes were log-transformed and analyzed using mixed effects models with a random intercept for endoscopist (in the case of procedure times) or facility (for pre-operative, anesthesia, and post-operative times). The initial position was used as the main factor.\u003c/p\u003e\u003cp\u003eAdditional analysis was performed after adjusting for endotracheal intubation, the treating physician/facility, number of interventions during the ERCP, and indication for ERCP to better understand impact of intubation and possible mediation of position effects through different rates of intubation. Estimates of group effect are presented as percent changes (with 95% confidence interval) of the untransformed variable from the reference group (prone position).\u003c/p\u003e\u003cp\u003eAssociation of procedure position with unanticipated hospitalization or urgent care was assessed using a multivariable mixed effects model adjusted for patient age, indication, number of procedures performed in surgery, treating facility/physician, urgency of care (elective vs emergent/urgent), body mass index, and type of anesthesia administered for the ERCP.\u003c/p\u003e\u003cp\u003eA p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant in all analyses. Statistical analysis was performed using R version 4.3.2 with the package lme4 used for mixed model analysis and variable importance computed using the package glmm.hp.\u003c/p\u003e\u003cp\u003e The study was approved by the institutional review board at Providence Sacred Heart Medical Center.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 6,510 patients across 11 hospitals in Washington state who underwent ERCP by 19 endoscopists met selection criteria, and were categorized into left lateral (N\u0026thinsp;=\u0026thinsp;2149), prone (N\u0026thinsp;=\u0026thinsp;999), and supine (N\u0026thinsp;=\u0026thinsp;3362) subgroups based on the initial position of the patient (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most of the patients underwent elective ERCP as outpatients. The most common indication for ERCP was biliary stone disease (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and the most common type of procedure was ERCP with stone removal (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOverall, endotracheal intubation was performed in 4567 (70%) patients. However, endotracheal intubation was performed more frequently in prone (937/999, 94%) and supine (3036/3362, 90%) vs left lateral (585/2149, 27%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) positions (Table\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eUnadjusted analysis\u003c/h3\u003e\n\u003cp\u003eUnadjusted time from patient entry to the procedure room till induction of anesthesia was 7.54\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95, 9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.22, 6.77\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67 minutes for left lateral, prone, and supine positions respectively (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly, the time from entry into the procedure room to being ready for the ERCP was 8.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15, 14.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41, and 9.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96 minutes for left lateral, prone, and supine positions respectively (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The duration of the ERCP and total time in the procedure room for left lateral, prone, and supine positions was 31.71\u0026thinsp;\u0026plusmn;\u0026thinsp;25.77, 40.99\u0026thinsp;\u0026plusmn;\u0026thinsp;28.6, 36.49\u0026thinsp;\u0026plusmn;\u0026thinsp;29.03 and 54.95\u0026thinsp;\u0026plusmn;\u0026thinsp;30.26, 72.61\u0026thinsp;\u0026plusmn;\u0026thinsp;32.76, 62.44\u0026thinsp;\u0026plusmn;\u0026thinsp;33.06 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for each) minutes, respectively. Mean time needed for exit from the procedure room after completion of the ERCP was also greater in patients treated in the prone position (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eRegression analysis\u003c/h2\u003e\u003cp\u003eMixed effects regression analyses were performed by adjusting for position alone as well as position along with endotracheal intubation (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). After adjusting for number of interventions performed during ERCP, there were significant reductions in time needed for pre-procedure assessment, time in room to anesthesia ready, total time in procedure room, and post-procedure time to room exit for left lateral position.\u003c/p\u003e\u003cp\u003eAfter further adjusting for endotracheal intubation, several time metrics showed significant improvements (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Supine positioning was associated with shorter pre-procedure assessment times compared to both left lateral and prone positions. Post-procedure room exit times were also reduced in the supine position compared to prone and left lateral position, as well as in the left lateral position compared to prone. Total procedure time was shorter in both supine and prone positions relative to left lateral, while total time in the procedure room was reduced in the supine position compared to both others, and in the prone position compared to left lateral (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eVariable importance analysis\u003c/h3\u003e\n\u003cp\u003eThe combined results demonstrated a strong mediation by endotracheal intubation, with increased efficiency in the left lateral position often completely explained by reduced rates of intubation. Subsequent variable importance analysis also demonstrated an outsized impact of endotracheal intubation on time needed to complete various components of the overall procedure, especially for induction of anesthesia, getting ready for the ERCP, and exiting the room after completion of the procedure. The duration of the ERCP was impacted by the number of interventions performed during ERCP (45%) as well as endotracheal intubation (55%).\u003c/p\u003e\u003cp\u003eNotably, the position of the patient did not have a significant impact on the duration of the actual endoscopic procedure.\u003c/p\u003e\n\u003ch3\u003eUnanticipated all-cause hospitalization\u003c/h3\u003e\n\u003cp\u003eIn unadjusted analysis, the incidence of all-cause unanticipated ER or hospital visits at 7 days and 30 days from the ERCP was the highest in the prone position compared to the supine and left lateral positions (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). After adjusting for clinical and procedural factors as well as random facility effects, only the difference in 7-day return visits was significantly lower in supine patients compared to prone (adjusted Odds ratio\u0026thinsp;=\u0026thinsp;0.63; 95% CI = (0.44, 0.91); p\u0026thinsp;=\u0026thinsp;.01). Adjusted differences in 30-day hospitalization were not significant between any groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eERCP remains a frequently performed therapeutic intervention for managing diverse pancreato-biliary conditions(\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This study assessed the overlapping impact of patient position as well as endotracheal intubation in terms of procedure efficiency and risk of adverse outcomes. To our knowledge, this is the largest study of its type to date. The study suggests that ERCP procedures performed in the left lateral or supine positions can reduce the need for endotracheal intubation and improve procedural metrics without an increase in the risk of hospitalization.\u003c/p\u003e\u003cp\u003eProne position is often the default position adopted by endoscopists due to its perceived benefits of improved ampullary position, better alignment of the bile duct, superior delineation of the pancreato-biliary anatomy and greater familiarity. There is a general reluctance to perform ERCP in the supine or left lateral position even among expert endoscopists(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Further, \u003cb\u003ei\u003c/b\u003enterpretation of the fluoroscopic images in the left lateral position can be challenging since the pancreatic and biliary wires often overlap in their initial course close to the ampulla. The filling of the right intrahepatic ducts may also be suboptimal in the left lateral position due to gravitational forces(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) but this is easily remedied by injecting more contrast during balloon occlusion cholangiography. This study reports that ERCP in the left lateral and supine positions can be used for all types of pancreato-biliary interventions.\u003c/p\u003e\u003cp\u003eDue to the alignment of the pancreas duct with the left lateral and supine positions, there is a higher likelihood of inadvertent PD cannulation and consequent post-ERCP pancreatitis with the left lateral and supine positions(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, cannulation of the pancreas duct can also facilitate its stenting, thus mitigating the risk of post-ERCP pancreatitis(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Indeed, a subgroup analysis by Mashiana et al, showed that supine and prone positions had similar rates of cardiopulmonary adverse events and post-ERCP pancreatitis(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Similarly, two prospective studies from Asia comparing the outcomes of left lateral and prone ERCP reported higher incidence of unintentional cannulation of the pancreatic duct but did not demonstrate an increase in the incidence of post ERCP pancreatitis(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) which could be due to maneuvers such as use of indomethacin suppository or pancreatic ductal stenting. Our study did not specifically assess rates of pancreatic duct cannulation but reports comparable incidence of post-ERCP readmission.\u003c/p\u003e\u003cp\u003eA prospective study by Issa et al, also demonstrated shorter procedure time and room turnover time with comparable cannulation rate for supine relative to prone ERCP procedures. However, this study was limited by modest sample size as there were only 17 patients placed in the prone position, and it did not address the underlying reasons for the shorter procedure time(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Our study demonstrates that increased efficiency with left lateral and supine positions occurs during the pre-procedure, intra-procedure as well as post-procedure portions of the ERCP.\u003c/p\u003e\u003cp\u003eThe prone position for the ERCP typically requires initial placement in the supine position, followed by endotracheal intubation, and finally turning the patient 180\u0026ordm; to be positioned prone. After the completion of the ERCP, all these steps need to be repeated in the reverse order. All these additional interventions require time and additionally entail the risk of dislodgement of chest leads, endotracheal tube, or the intravenous access. Further, turning obese patients by 180\u0026ordm; for ERCP in the prone position provides additional risks of significant ergonomic injury to healthcare personnel(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). ERCP with the patient in the left lateral or supine position may be more comfortable for the patient, eases transfer to and from the fluoroscopy table to the gurney, and allows for better control of the airway and resuscitation maneuvers while also avoiding ergonomic injury to medical personnel (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Indeed, the recent consensus guideline created by an international group of expert anesthesiologists and gastroenterologists favors the use of monitored anesthesia care without endotracheal intubation and restricts the use of general anesthesia with endotracheal intubation in select patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The results of this study provide data to support these recommendations.\u003c/p\u003e\u003cp\u003eComparative data analyzing the outcomes of ERCP in the supine, prone, and left lateral position are lacking and typically restricted to single-center studies of modest sample sizes. A recent systematic review and meta-analysis found only 6 studies of which 3 were limited to abstracts, including one abstract with the largest number of patients. The analysis was limited by publication bias, substantial heterogeneity in the source studies, and few patients in the supine position(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Tringali and colleagues performed a study of 120 patients and found no difference in the outcomes of ERCP performed in the supine or prone position(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Terruzzi and colleagues on the other hand performed a small study of 17 patients in each position and demonstrated failure of biliary cannulation in 29% of patients and a higher incidence of cardiopulmonary adverse events in the supine position (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Similarly, a retrospective study using the Clinical Outcomes Research Initiative database reported shorter procedure times and comparable fluoroscopy time with the supine position compared to the prone position (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Other endoscopists have also reported comparable rates of biliary access with left lateral and prone positions(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study is strengthened by its large sample size and ability to analyze multiple confounding variables such as the frequency of endotracheal intubation, position of the patient, indication and urgency of the ERCP, and hospital and physician specific variables. The utilization of a large database helps in overcoming limitations of sample size and facilitates the performance of analysis with appropriate statistical power(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The study also assesses diverse experiences of multiple endoscopists working in varied hospital settings of different size thus increasing the generalizability of the findings. The study is limited by its retrospective study design and lack of procedure-specific details such as cannulation rates or fluoroscopy time. Comparisons of procedural metrics in different positions are complicated by the strong confounding with intubation. The choice of position is highly associated with the surgeon and/or facility, raising the possibility of residual confounding by other provider effects. The number of patients in the prone position were fewer than those in the supine and left lateral positions. Finally, adverse events have not been categorized into cardiopulmonary/anesthesia related versus those secondary to the procedure itself such as bleeding or post ERCP pancreatitis. However, the incidence of post-ERCP unplanned hospitalization serves as an appropriate surrogate for common adverse events associated with ERCP.\u003c/p\u003e\u003cp\u003eThis study suggests that ERCP in the left lateral or supine position is time efficient, reduces need for universal endotracheal intubation, without increasing the risk of post-ERCP hospitalization. At one tertiary care high-volume referral center included within our network, all ERCP procedures are performed in the left lateral position and endotracheal intubation is performed solely at the discretion of the anesthesiologist based on the patient\u0026rsquo;s clinical status.\u003c/p\u003e\u003cp\u003eWe posit that the decision to perform endotracheal intubation should be decided solely on the needs of the patient rather than the position of the patient during ERCP. These data demonstrate that endoscopists can perform ERCP in the left lateral or supine position without universal endotracheal intubation the patients and placing them in the prone position. Large prospective multi-center studies are needed to confirm the findings of this study.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics and patient characteristics who underwent Endoscopic retrograde cholangiopancreatography (ERCP)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6510)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLeft lateral\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2149)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProne\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;999)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSupine\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;3362)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDemographics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60.28\u0026thinsp;\u0026plusmn;\u0026thinsp;17.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.37\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;17.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3459 (53%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1119 (52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e539 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1801 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3051 (47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1030 (48%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e460 (46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1561 (46%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eRace\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4976 (76%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1765 (82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e815 (82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2396 (71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e451 (7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e461 (11%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e192 (3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e162(5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.15\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.12\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27.82\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody surface area (m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInpatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1031 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e270 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e175 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e586 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutpatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5479 (84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1879 (87%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e824 (82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2776 (83%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrgency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4921 (76%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1487 (69%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e824 (82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2610 (78%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrgent or emergent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1589 (24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e662 (31%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e175 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e752 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnesthesia type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral anesthesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5158 (79%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1096 (51%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e937 (94%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3125 (93%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Intra-venous Anesthesia (TIVA)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e715 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e532 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42 (4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e141 (4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonitored anesthesia care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e637 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e521 (24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e96 (3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAirway\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntubated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4567 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e585 (27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e946 (95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3036 (90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot intubated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1943 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1564 (73%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53 (5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e326 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll entries are either mean +/- SD or count (column %). p-values are calculated using either one-way ANOVA (continuous variables) or chi-squared tests of proportions (categorical variables).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIndications for Endoscopic retrograde cholangiopancreatography (ERCP)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6510)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLeft lateral\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2149)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProne\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;999)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSupine\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;3362)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBiliary disorders\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4977 (76.45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1666 (77.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e865 (86.59%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2446 (72.75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiliary lithiasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e787\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"8\" rowspan=\"9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiliary pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e143\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary sclerosing cholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiliary stricture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e765\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBile leak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication of liver transplant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdjustment of prosthesis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther biliary disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e599\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e296\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePancreatic disorders\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e992 (15.24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e309 (14.38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59 (5.91%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e624 (18.56%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e684\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e403\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreas duct leak / disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMalignant disorders\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e345 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97 (4.51%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (4.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e203 (6.04%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholangiocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreas malignancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMiscellaneous or unclear\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e164 (2.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58 (2.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (2.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77 (2.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSphincter of Oddi dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAmpullary disorders\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (0.49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (0.88%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (0.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmpullary adenoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) procedures performed\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP Procedure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCPT code\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6510)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft lateral\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2149)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eProne\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;999)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSupine\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;3362)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP Diagnostic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43260\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e170 (2.61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71 (3.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 (2.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e75 (2.23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with biopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43261\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e512 (7.86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e140 (6.51%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e78 (7.81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e294 (8.74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with sphincterotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1287 (19.77%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e442 (20.57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e311 (31.13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e534 (15.88%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with manometry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with stone removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43264\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3843 (59.03%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1147 (53.37%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e583 (58.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2113 (62.85%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with lithotripsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e136 (2.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39 (1.81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36 (3.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e61 (1.81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholangioscopy or pancreatoscopy (in conjunction with ERCP)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e212 (3.26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72 (3.35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53 (5.31%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87 (2.59%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with stent placement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1774 (27.25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e660 (30.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e203 (20.32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e911 (27.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with removal of stent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1295 (19.89%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e493 (22.94%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e226 (22.62%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e576 (17.13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with stent exchange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1719 (26.41%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e421 (19.59%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e182 (18.22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1116 (33.19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with balloon dilation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e289 (4.44%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e106 (4.93%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e146 (4.34%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.272\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eERCP with ablation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43278\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72 (1.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (1.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e39 (1.16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll n represents number of patients in the column who received at least one intervention of the type indicated in the row. p-values for chi-squared analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnadjusted time intervals in minutes (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation) during Endoscopic retrograde cholangiopancreatography (ERCP) in patients placed in different positions\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime interval\u003c/p\u003e\u003cp\u003e(minutes; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6510)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLeft lateral\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2149)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProne\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;999)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSupine\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;3362)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003ePre-procedure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.56\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.24\u0026thinsp;\u0026plusmn;\u0026thinsp;15.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.38\u0026thinsp;\u0026plusmn;\u0026thinsp;21.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;18.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInduction of anesthesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.54\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.77\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEntry in to procedure room to being ready for ERCP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eIntra-procedure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of ERCP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35.56\u0026thinsp;\u0026plusmn;\u0026thinsp;28.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.71\u0026thinsp;\u0026plusmn;\u0026thinsp;25.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.99\u0026thinsp;\u0026plusmn;\u0026thinsp;28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36.49\u0026thinsp;\u0026plusmn;\u0026thinsp;29.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal time in procedure room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.53\u0026thinsp;\u0026plusmn;\u0026thinsp;32.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.95\u0026thinsp;\u0026plusmn;\u0026thinsp;30.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72.61\u0026thinsp;\u0026plusmn;\u0026thinsp;32.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.44\u0026thinsp;\u0026plusmn;\u0026thinsp;33.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003ePost procedure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompletion of ERCP to exit from procedure room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.09\u0026thinsp;\u0026plusmn;\u0026thinsp;5.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.79\u0026thinsp;\u0026plusmn;\u0026thinsp;6.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.89\u0026thinsp;\u0026plusmn;\u0026thinsp;5.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIncidence of unanticipated emergency room or hospital visit after Endoscopic retrograde cholangiopancreatography (ERCP). Adjusted odds ratio (aOR) using prone position as reference in model adjusted for age, indication, number of surgical procedures, BMI, urgency of procedure, and type of anesthesia administered. Data presented as odds ratio (95% confidence interval; P-value)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHospitalization\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5479)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLeft lateral (n\u0026thinsp;=\u0026thinsp;1879)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProne (n\u0026thinsp;=\u0026thinsp;824)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSupine (n\u0026thinsp;=\u0026thinsp;2776)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUnadjusted P-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eWithin 7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e253 (4.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (5.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (5.95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109 (3.93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82(0.55\u0026ndash;1.24; 0.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eReference\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63* (0.44, 0.91; p\u0026thinsp;=\u0026thinsp;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eWithin 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e748 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e269 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e134 (16.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e345 (12.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88(0.64,1.21; 0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eReference\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83 (0.58, 1.8; 0.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eERCP: Endoscopic retrograde cholangiopancreatography, ANOVA: Analysis of variance\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the assistance of Nora Mertens, Kendra Fledderman, Rebecca Hart, and Alicia Graves in performing this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eauthor contribution: \u003c/strong\u003eDRK: Data analysis, initial draft, and revision of manuscript; DAH: statistical analysis; NP, JB, WS: procedures, revision of manuscript \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eNone \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFINANCIAL DISCLOSURE\u003c/strong\u003e: DRK: Research support, equipment loan from Fujifilm for unrelated project\u003c/p\u003e\n\u003cp\u003eAll other authors: None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWilcox CM. Should patients undergoing ERCP be placed in the prone or supine position? Nat Clin Pract Gastroenterol Hepatol. 2008 Sep;5(9):488\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eOsagiede O, Bola\u0026ntilde;os GA, Cochuyt J, Cruz LM, Kr\u0026ouml;ner PT, Lukens FJ, et al. Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: a retrospective study. Ann Gastroenterol. 2021;34(4):582\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMashiana HS, Jayaraj M, Mohan BP, Ohning G, Adler DG. Comparison of outcomes for supine vs. prone position ERCP: a systematic review and meta-analysis. Endosc Int Open. 2018 Nov;6(11):E1296\u0026ndash;301. \u003c/li\u003e\n\u003cli\u003eTerruzzi V, Radaelli F, Meucci G, Minoli G. Is the supine position as safe and effective as the prone position for endoscopic retrograde cholangiopancreatography? A prospective randomized study. Endoscopy. 2005 Dec;37(12):1211\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eFerreira LEVVC, Baron TH. Comparison of safety and efficacy of ERCP performed with the patient in supine and prone positions. Gastrointest Endosc. 2008 Jun;67(7):1037\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eTringali A, Mutignani M, Milano A, Perri V, Costamagna G. No difference between supine and prone position for ERCP in conscious sedated patients: a prospective randomized study. Endoscopy. 2008 Feb;40(2):93\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAlam L, Khan RSA, Saeed F, Sher F, Khan RZA. Does patient\u0026rsquo;s position count during Endoscopic Retrograde Cholangio-pancreatography? Left lateral decubitus versus prone position. Pak J Med Sci. 2023;39(5):1232\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKohli DR, Kennedy KF, Desai M, Sharma P. Comparative Safety of Endoscopic vs Radiological Gastrostomy Tube Placement: Outcomes From a Large, Nationwide Veterans Affairs Database. Am J Gastroenterol. 2021 Sep 10; \u003c/li\u003e\n\u003cli\u003eKohli DR, Kennedy KF, Desai M, Sharma P. Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment. Gastrointest Endosc. 2020 Sep 12; \u003c/li\u003e\n\u003cli\u003eASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017 Jan;85(1):32\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eFujii-Lau LL, Thosani NC, Al-Haddad M, Acoba J, Wray CJ, Zvavanjanja R, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: summary and recommendations. Gastrointest Endosc. 2023 Nov;98(5):685\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eKohli DR, Amateau SK, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, et al. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: summary and recommendations. Gastrointest Endosc. 2023 Apr;97(4):607\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eSachdev A, Kashyap JR, D\u0026rsquo;Cruz S, Kohli DR, Singh R, Singh K. Safety and efficacy of therapeutic endoscopic interventions in the management of biliary leak. Indian J Gastroenterol. 2012 Sep;31(5):253\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eASGE Standards of Practice Committee, Sheth SG, Machicado JD, Chalhoub JM, Forsmark C, Zyromski N, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: summary and recommendations. Gastrointest Endosc. 2024 Oct;100(4):584\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eFroehlich F. Patient position during ERCP: prone versus supine. What about left lateral throughout? Endoscopy. 2006 Jul;38(7):755; author reply 755. \u003c/li\u003e\n\u003cli\u003eVarma P, Ket S, Paul E, Barnes M, Devonshire DA, Croagh D, et al. Does ERCP position matter? A randomized controlled trial comparing efficacy and complications of left lateral versus prone position (POSITION study). Endosc Int Open. 2022 Apr;10(4):E403\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eBuxbaum JL, Freeman M, Amateau SK, Chalhoub JM, Coelho-Prabhu N, Desai M, et al. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc. 2023 Feb;97(2):153\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003ePark TY, Choi SH, Yang YJ, Shin SP, Bang CS, Suk KT, et al. The efficacy and safety of the left lateral position for endoscopic retrograde cholangiopancreatography. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc. 2017;23(5):296\u0026ndash;302. \u003c/li\u003e\n\u003cli\u003eIssa D, Sharaiha RZ, Abdelfattah T, Htway Z, Tabibian JH, Thiruvengadam S, et al. Clinical outcomes and learning curve for ERCP during advanced endoscopy training: a comparison of supine versus prone positioning. Gastrointest Endosc. 2023 Oct;98(4):629-633.e1. \u003c/li\u003e\n\u003cli\u003ePawa S, Kwon RS, Fishman DS, Thosani NC, Shergill A, Grover SC, et al. American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations. Gastrointest Endosc. 2023 Oct;98(4):482\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eAzimaraghi O, Bilal M, Amornyotin S, Arain M, Behrends M, Berzin TM, et al. Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography. Br J Anaesth. 2023 Jun;130(6):763\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eKohli DR, Desai M, Kennedy KF, Parasa S, Sharma P. Cholecystectomy for Biliary Pancreatitis Is Often Not Performed During Index Hospitalization and Is Associated With Worse Outcomes. Clin Gastroenterol Hepatol. 2020 Dec 8; \u003c/li\u003e\n\u003cli\u003eKohli DR, Desai MV, Kennedy KF, Pandya P, Sharma P. Patients with post-transplant biliary strictures have significantly higher rates of liver transplant failure and rejection: A nationwide inpatient analysis. J Gastroenterol Hepatol. 2020 Dec 29; \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 5","content":"\u003cp\u003eTable 5 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"ERCP, Endotracheal Intubation, outcomes, prone position","lastPublishedDoi":"10.21203/rs.3.rs-7458267/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7458267/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) is conventionally performed in the prone position after intubating the airway. However, ERCP can also be performed in the left lateral and supine positions without endotracheal intubation. We compared procedural metrics and outcomes in patients placed prone, supine, and left lateral during ERCP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective multi-center analysis using a large, organization-wide database, patients were categorized as prone, supine, and left lateral based on the positioning for ERCP. Procedural metrics were calculated using contemporaneous electronic health records. All-cause readmission within 7 days and 30 days of ERCP was analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 6510 patients who met selection criteria were categorized as follows: Supine: 3362; left lateral: 2149; and prone: 999. Endotracheal intubation was performed more frequently in supine (90%) and prone (95%) positions than left lateral position (27%; p \u0026lt; 0.01). The time intervals (minutes) for left lateral, prone, and supine positions were: induction time 7.54 ± 4.95, 9.3 ± 6.22, 6.77 ± 3.67; anesthesia ready time 8.98 ± 5.15, 14.13 ± 7.41, 9.41 ± 3.96; ERCP duration 31.71 ± 25.77, 40.99 ± 28.6, 36.49 ± 29.03 and total time in room 54.95 ± 30.26, 72.61 ± 32.76, 62.44 ± 33.06 (p \u0026lt; 0.001 for each measure between three groups) respectively. Regression and variable impact analysis demonstrated that endotracheal intubation was the most significant factor for increased induction time (100%), anesthesia ready time (97%), and duration of ERCP (55%). Adjusted odds of readmission at 7 days were lower in supine patients compared to prone (0.63; 95%CI 0.44,0.91; p = 0.01)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupine and left lateral positions improve procedural efficiency primarily due to reduced endotracheal intubation rates, without increasing readmission.\u003c/p\u003e","manuscriptTitle":"Impact of Patient Positioning and Endotracheal Intubation During Ercp: Insights From a Large Database","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 14:39:59","doi":"10.21203/rs.3.rs-7458267/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-28T23:15:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T13:40:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335602157123116388328874084158115264070","date":"2025-09-15T14:46:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-14T21:23:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30394604184768609729922750824496160111","date":"2025-09-03T19:48:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-02T23:36:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-27T02:17:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-26T12:04:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-08-26T03:22:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ac866c03-8c1c-400f-9934-0aafd114d0d8","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:03:49+00:00","versionOfRecord":{"articleIdentity":"rs-7458267","link":"https://doi.org/10.1007/s10620-025-09548-0","journal":{"identity":"digestive-diseases-and-sciences","isVorOnly":false,"title":"Digestive Diseases and Sciences"},"publishedOn":"2025-11-25 15:58:19","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-09-09 14:39:59","video":"","vorDoi":"10.1007/s10620-025-09548-0","vorDoiUrl":"https://doi.org/10.1007/s10620-025-09548-0","workflowStages":[]},"version":"v1","identity":"rs-7458267","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7458267","identity":"rs-7458267","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}