Patient position during ERCP: prone versus supine. What about left lateral throughout?

I read with interest the article by Terruzzi et al. [ 1 ] investigating the safety and effectiveness of patient positioning during endoscopic retrograde cholangiopancreatography (ERCP). Although the study is small, the authors have addressed an important clinical issue. They show that ERCP is more difficult and less often successful when it is conducted with the patient in the supine position in comparison with the prone position. Most endoscopists start ERCP with the patient in the left lateral position until the papilla is reached, and then change to the prone position. However, the prone position can impair flow in the vena cava and mesenteric veins [ 2 ] and in addition may not be possible in patients with major neck problems, due to inability to turn the head to the right (e. g., in those with arthrosis or Parkinson’s disease). In my experience, ERCP can be well continued in the left lateral position - much to the relief of the anesthesiologist - with a biliary access rate that appears to be comparable to that in the prone position. However, the endoscopy suite has to be equipped with a mobile radiography system that allows the beam to be directed horizontally from the back to the front of the patient. The only disadvantage I have noticed with this technique is that the right hepatic duct and intrahepatic biliary tree fill less completely in the left lateral position, presumably due to hydrostatic pressure differences. This may occasionally require the prone position at the end of the procedure in order to improve the imaging quality. The left lateral position may also be preferable for endoscopists who carry out ERCP without an anesthesiologist and without intubation, due to the lower risk of aspiration and better access to the patient’s mouth. One may wonder about the safety (e. g., the risk of aspiration) of the supine position in nonintubated patients in the study by Terruzzi et al. [ 1 ], even though the patient’s head was kept in the left lateral position with continuous saliva aspiration. Competing interests: none