Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis

Abstract

Background and aim: There is wide variation in choice of sedation and airway management for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review and meta-analysis to investigate safety outcomes of deep sedation with monitored anesthesia care (MAC) versus general endotracheal anesthesia (GETA).

Methods: Individualized search strategies were performed in accordance with PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions using random effects models. Measured outcomes included procedure success, all-cause and anesthesia-associated adverse events, and post-procedure recovery time. Heterogeneity was assessed with I² statistics and publication bias by funnel plot and Egger regression testing.

Results: Five studies (MAC: n = 1284 vs GETA: n = 615) were included. Patients in the GETA group were younger, had higher body mass index (BMI), and higher mean ASA scores (all P < 0.001) with no difference in Mallampati scores (P = 0.923). Procedure success, all-cause adverse events, and anesthesia-associated events were similar between groups [OR 1.16 (95% CI 0.51-2.64); OR 1.16 (95% CI 0.29-4.70); OR 1.33 (95% CI 0.27-6.49), respectively]. MAC resulted in fewer hypotensive episodes [OR 0.32 (95% CI 0.12-0.87], increased hypoxemic events [OR 5.61 (95% CI 1.54-20.37)], and no difference in cardiac arrhythmias [OR 0.48 (95% CI 0.13-1.78)]. Procedure time was decreased for MAC [standard difference - 0.39 (95% CI - 0.78-0.00)] with no difference in recovery time [standard difference - 0.48 (95% CI - 1.04-0.07)].

Conclusions: This study suggests MAC may be a safe alternative to GETA for ERCP; however, MAC may not be appropriate in all patients given an increased risk of hypoxemia.

Keywords: Adverse events; Anesthesia; Endoscopic retrograde cholangiopancreatography (ERCP); Endoscopy; Sedation.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Chart of Literature Search Results

Figure 2.

Figure 2A. Total Anesthesia-Associated Adverse Events with Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA) Figure 2B. Hypotension-Associated Adverse Events with Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA) Figure 2C. Hypoxemia-Associated Adverse Events with Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA) Figure 2D. Cardiac Arrhythmia-Associated Adverse Events with Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA)

Figure 3.

Figure 3A. All-Cause Adverse Events with Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA) Figure 3B. Rate of Procedures Converted From Deep Sedation under Monitored Anesthesia Care (MAC) to General Endotracheal Anesthesia (GETA) Figure 3C. Mean Procedure Time for Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA) Figure 3D. Mean Time to Recovery Post-Endoscopic Cholangiopancreatography (ERCP): Deep Sedation under Monitored Anesthesia Care (MAC) Versus General Endotracheal Anesthesia (GETA)

Figure 4.

Figure 4A: Funnel Plot of Publication Bias and Eggers Regression Test for Included Studies Figure 4B: Funnel Plot of Publication Bias with Duval and Tweedie’s Trim and Fill Method.