Should patients undergoing ERCP be placed in the prone or supine position?

Endoscopic retrograde cholangiopancreatography (ERCP) is generally performed in the prone or semi-prone position. Compared with the supine position, the left lateral and prone positions are believed to carry a lower risk of aspiration, allow easier intubation of the esophagus and provide a more comfortable position for the endoscopist. However, the supine position might be advantageous for the evaluation of pancreatic and biliary anatomy and for enhanced control of the airway. In this Practice Point commentary, I discuss the findings and limitations of a prospective, randomized study conducted by Tringali et al. that compared the performance of ERCP in the prone and supine positions by both experienced endoscopists and trainees. The results suggest no difference in the difficulty of the procedure on the basis of patient position. Objective measurements including mean time to visualize the papilla and opacification of the desired duct were no different. Likewise, overall technical success and complication rates were equivalent. These results suggest that either the supine or prone positions are adequate for the technical performance of ERCP. This commentary highlights the issues to consider when interpreting and generalizing these results in clinical practice.