Deep sedation or general anesthesia for ERCP

Ideal sedation for endoscopic procedures should maximize patient comfort and safety. However, during many endoscopic procedures performed under conscious (i.e., moderate) sedation, patient comfort is compromised to some extent in the interest of safety. Although conscious sedation was the mainstay for most endoscopic procedures over the initial decades of endoscopy, anesthesia services have increasingly been utilized over recent years to provide deeper levels of sedation [1]. The key driver for increased anesthesia utilization over the last decade has been the need to improve patient comfort, satisfaction, and safety while simultaneously improving the efficiency of endoscopy units. A significant facilitating factor has been the introduction and availability of new pharmaceutical agents such as propofol, which allow rapid induction of deep sedation while also enabling rapid recovery [2]. Propofol sedation for gastroscopy and colonoscopy is as safe as sedation using traditional agents, whether administered by anesthesia providers or under the direction of endoscopists [3]. Numerous studies attest to its benefits, including improved patient cooperation during the procedure, improved patient satisfaction, reduced procedural and recovery times, and, consequently, improved throughput and efficiency of endoscopy units [4]. In 2007, approximately 25 % of U.S. colonoscopies and gastroscopies were performed with anesthesiologist-assisted sedation [1]. Given the relative simplicity and brevity of many of these basic endoscopic procedures and the significant cost burden associated with the use of anesthesia, this practice remains controversial and consequently has not been universally adopted. In contrast, endoscopic retrograde cholangiopancreatography (ERCP) is a more complex endoscopic procedure that usually takes longer to perform. A recent study evaluating patients undergoing ERCP under conscious sedation found that between a third and a half of patients experienced pain and discomfort during the procedure and periprocedural period [5]. An additional study indicated that the procedural failure rate in patients undergoing ERCP with sedation was double the failure rate when general anesthesia was utilized (14 vs. 7 %). The higher failure rate with conscious sedation was entirely due to ERCPs that were terminated prematurely (8.5 %) due to inadequate sedation [6]. These data constitute powerful arguments for the use of deep propofol sedation or general anesthesia in patients undergoing ERCP and, indeed, this is the trend in many academic medical centers across the U.S. However, there is a dearth of literature evaluating the most appropriate type of sedation or anesthesia for complex endoscopic procedures such as ERCP. A recent Cochrane review identified only four randomized controlled studies comparing moderate sedation using midazolam and meperidine with propofol administered by non-anesthesiologists for ERCP. No difference in mortality, serious cardio-respiratory complications, or patient satisfaction between the two sedation techniques was noted, although patients receiving propofol sedation had a faster and better recovery profile [7]. From the viewpoint of endoscopy room efficiency, propofol sedation where safe is preferable to general anesthesia as it allows for a more rapid procedure room turnover. Anesthesia practices vary from center to center and also between anesthesiologists at the same center, with some anesthesiologists judiciously choosing between deep N. Thosani S. Banerjee (&) Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA e-mail: sbanerje@stanford.edu