Endoscopy 2016; 48(03): 297
DOI: 10.1055/s-0035-1569651
Letters to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Nature of sedation and post-ERCP pancreatitis: is it a question of sedation “not being in my department”?

Andrew Thomson
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Publication History

Publication Date:
23 February 2016 (online)

In the recent Endoscopy article by Yaghoobi et al. [1], which compared pancreatic sphincterotomy with a sham procedure, there is a good deal of discussion about the lack of association between pancreatic sphincterotomy and an increased risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The authors also looked at potential confounders, including procedure duration and type of sedation. For patients who underwent procedures with monitored anesthesia care (MAC), longer procedure duration was associated with an increased risk of PEP, whereas for patients under moderate sedation and general anesthesia, no such relationship was apparent – indeed the reverse trend was seen. This disparity was described by the authors as “not clinically plausible.” It is assumed that moderate sedation involved the administration of an intravenous benzodiazepine and possibly a narcotic by nursing staff either in a semi-autonomous fashion consistent with a protocol or under the contemporaneous direction of the endoscopist. MAC presumably refers to patients being given propofol (with or without other intravenous agents) by an anesthesiologist, and general anesthesia, it is assumed, refers to patients being even more heavily sedated by an anesthesiologist to enable endotracheal untubation.

There is evidence in the literature that pain experienced during moderate sedation is associated with PEP [2]. There is also an association between longer procedure time and PEP [3]. With respect to the study by Yaghoobi et al., procedures may have been curtailed in the moderate sedation group because of patient intolerance, and PEP may thus have been prevented. In the early part of my career, I can well remember doing ERCPs with this type of sedation. Sometimes patients needed physical restraint by multiple healthcare workers in order to complete the procedure, and there could be significant pressure to complete procedures promptly. In contrast, in the MAC group, with the heavier sedation and the attendance of a specialist anesthesiologist, precipitating pancreatitis with multiple cannulations and other manipulations may have been more likely. In this scenario, patient discomfort or restlessness during ERCP is quickly and efficiently resolved by highly trained specialist colleagues, and the issue of maintaining adequate levels of sedation is thus “not in my (i. e. the endoscopist’s) department.” With MAC, the procedure can continue even if the risk of pancreatitis keeps rising. This explanation, however, cannot be invoked to explain the decreasing risk of PEP with procedure time encountered in those who were sedated with general anesthesia. The choice between MAC and general anesthesia is very much down to the attending anesthesiologist. Were there differences between centers in the predilection for the type of sedation used? Was there another potential confounding factor such as age, sex, or previous pancreatitis to explain the findings?

Notwithstanding the paucity of discussion in the paper, the data with respect to sedation type are interesting and intriguing and, in my view, merit further exploration.

 
  • References

  • 1 Yaghoobi M, Pauls Q, Durkalski V et al. Incidence and predictors of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction undergoing biliary or dual sphincterotomy: results from the EPISOD prospective multicenter randomized sham-controlled study. Endoscopy 2015; 47: 884-890
  • 2 Vandervoort J, Soetikno RM, Tham TC et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56: 652-656
  • 3 Fisher L, Fisher A, Thomson A. Cardiopulmonary complications of ERCP in older patients. Gastrointest Endosc 2006; 63: 948-955