Does Anesthesiologist-Directed Sedation Afford Superior Deep Cannulation Rates and Procedural Outcomes for ERCP in the Community Setting?

Abstract

Aim: To compare outcomes by sedation class in community patients undergoing index endoscopic retrograde cholangiopancreatography (ERCP). Methods: Nineteen hundred sixteen consecutive patients underwent ERCP from May 2005 to May 2011. Eight hundred thirty seven patients were excluded due to prior papillary intervention or attempted ERCP. A total of 1079 patients were included. The 981 patients who underwent gastroenterologist directed sedation (GDS) served as the control population, while the 98 patients who received anesthesiologist directed sedation (ADS) served as the case population. Medical records were analyzed for patient demographics, procedure indication, adverse events, case complexity, procedural failure and sedation failure. Case complexity was defined by the grading system proposed by the working party of the ASGE Quality Committee. Sedation failure was defined by agitation or airway compromise prompting termination of the ERCP. Reasons for procedural failure included surgically altered anatomy, luminal obstruction, and technical failure. Study endpoint was defined as successful deep cannulation of the intended target duct. Results: Demographic distribution did not differ between the GDS and the ADS groups. Cannulation success rates were similar between the two groups, with 89.85% in the GDS group, and 89.58% in the ADS group (P = 0.864). There were no statistical differences between sedation groups in procedural or respiratory adverse events. Technical failure was the predominant basis for deep cannulation failure in both groups. Agitation and airway compromise accounted for deep cannulation failure similarly in both groups. The need for reversal agents was low but similar in both groups. There was no statistical advantage in deep cannulation success rate by complexity grade in either sedation class. Conclusion: Excellent procedural outcomes and low adverse event rates were achieved using GDS, a more accessible and cost-effective method in a community-based setting.