Introduction:
Endoscopic retrograde pancreatography (ERCP) has traditionally been performed in prone or left lateral decubitus position with the presumption that visualization/cannulation of the biliary and pancreatic ducts are more advantageous, despite turning the patient from the supine position. Adult data is mixed on the benefits of prone versus supine positioning. There is a paucity of data in the pediatric setting, with concerns that longer anesthesia time in children is associated with a higher risk for neurocognitive effects. Our study hypothesized that supine ERCP position has similar safety and technical outcomes as prone ERCP with shorter anesthesia duration due to decreased time required to position patients safely.

Methods:
Our center routinely performed ERCP in prone position until 2018 when both providers performing pediatric ERCP evolved their practice to perform ERCP supine. Retrospective chart review was done from September 2016-August 2023 of all ERCPs done at our center. Data included patient demographics, procedural information, and adverse events. Statistics were done using IBM SPSS Statistics v29 (Armonk, NY)

Results:
A total of 294 patients (406 ERCPs) were reviewed. 11 patients (31 ERCPs) were excluded due to post-surgical anatomy. 198 patients (52.3%) were positioned supine while 180 (47.7%) were positioned prone. Table 1 shows results by position. Overall post-ERCP pancreatitis was 7.8% (6.1% supine, 10% prone). In the prone cohort, there was higher fellow involvement and more native papilla cases while the supine cohort had a greater proportion of biliary indications. Mean anesthesia time was significantly less in the supine group, (94.9 + 44.2 min vs 107.8 + 52.5 min, p=0.01), without difference in procedure time. For native papilla cases with biliary indications, there was no significant difference in rates of unintentional PD cannulation by position (32% vs 38%, p = 0.16). Table 2 shows multivariate stepwise linear regression with the primary outcome of total anesthesia time. Supine position, procedure success and weight increase (kg) were associated with a decrease in total anesthesia time. Additional procedure, native papilla and unintentional pancreatic duct cannulation were associated with an increased total anesthesia time. Age, BMI, Gender, Proceduralist, position change, fellow involvement and procedure indication were not significant in the final model.

Discussion:
This is the first pediatric study to evaluate pediatric ERCP outcomes based on positioning. Supine position was associated with shorter total anesthesia time with similar procedure time. Our analysis did not reveal differences in procedural success, radiation exposure or adverse events based on patient position. This study demonstrates ERCP can be performed in supine position safely in pediatric patients with decreased exposure to anesthesia.

Rebecca Schiff

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