British Journal of Anaesthesia, 130 (6): 763e772 (2023)

doi: 10.1016/j.bja.2023.03.012
Advance Access Publication Date: 14 April 2023
Special Article

QUALITY AND PATIENT SAFETY

Consensus guidelines for the perioperative management of patients

undergoing endoscopic retrograde cholangiopancreatography
Omid Azimaraghi1, Mohammad Bilal2 , Somchai Amornyotin9, Mustafa Arain3,
Matthias Behrends4, Tyler M. Berzin5 , James L. Buxbaum6, Curtis Choice1 ,
Philipp Fassbender1,7, Mandeep S. Sawhney5, Eswar Sundar8 , Karuna Wongtangman1,9 ,
Kate Leslie10,11 and Matthias Eikermann1,12,*
1
Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY,
USA, 2Division of Gastroenterology & Hepatology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis,
MN, USA, 3Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA, 4Department of Anesthesia and
Perioperative Care, University of California, San Francisco, CA, USA, 5Division of Gastroenterology, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA, 6Department of Internal Medicine, University of Southern
€ sthesiologie, Operative Intensivmedizin,
California, Keck School of Medicine, Los Angeles, CA, USA, 7Klinik für Ana
€ tsklinikum der Ruhr-Universita
Schmerz- und Palliativmedizin, Marien Hospital Herne, Universita € t Bochum, Herne,
Germany, 8Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA, 9Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
10
University, Bangkok, Thailand, Monash University, Melbourne, VIC, Australia, 11Royal Melbourne Hospital and
€ sthesiologie und Intensivmedizin, Universita
University of Melbourne, Melbourne, VIC, Australia and 12Klinik für Ana €t
Duisburg-Essen, Essen, Germany

*Corresponding author. E-mail: meikermann@montefiore.org

Summary
Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intu-
bation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There
are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be
considered depending on the nature and severity of the patient’s underlying disease, comorbidities, and procedural risks.
An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions
regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for
planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical rec-
ommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while
maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations
favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and
those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with
tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between
monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for
ERCP. An individual riskebenefit analysis that takes into account provider and institutional experience, patient
comorbidities, and procedural risks is also needed.

Keywords: ERCP; general anaesthesia; guideline; hypotension; hypoxaemia; monitored anaesthesia care; perioperative
outcomes

Received: 29 October 2022; Accepted: 8 March 2023

© 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

763
 764 - Azimaraghi et al.
Editor’s key points
 Using a modified Delphi process, expert anaesthesi-
ologists and gastroenterologists created guidelines
regarding the use of monitored anaesthesia care vs
general anaesthesia for endoscopic retrograde chol-
angiopancreatography (ERCP).
 Monitored anaesthesia care is the favoured anaes-
thesia plan for ERCP for short routine procedures.
 Increased risk of pulmonary aspiration and pro-
longed procedures of high complexity favour general
anaesthesia with tracheal intubation.
 Provider and institutional experience, patient
comorbidities, and procedural risks are also impor-
tant considerations.
The number of endoscopic retrograde cholangiopancreatog-
raphy (ERCP) procedures performed is increasing. In the USA
alone, more than 600 000 ERCP procedures are performed
annually.1 ERCP involves complex interventions that affect the
duodenum, biliary tract, and liver, and it carries a risk of acute
pancreatitis, bleeding, perforation, and infection.2 Anaes-
thesia- and sedation-related complications include haemo-
dynamic instability, haemoglobin desaturation, pulmonary
aspiration, and apnoea.3
In recent years, more ERCP procedures have been con-
ducted under monitored anaesthesia care (MAC) than under
general anaesthesia with tracheal intubation.4e7 There are
limited data on the riskebenefit of conducting ERCP under
monitored anaesthesia care vs general anaesthesia.8 The
choice of anaesthetic technique might affect the adverse
events risk and also has implications for efficiency and
staffing (as general anaesthesia is usually more time
consuming, limiting the number of procedures that can be
performed per session). Currently, decisions on the choice of
anaesthesia are based on local resources and institutional
preferences.
Our aim was to provide recommendations for the use of
deep sedation without tracheal intubation (monitored anaes-
thesia care) vs general anaesthesia with tracheal intubation
using a modified Delphi process. We took into account patient
comorbidities, procedural risks, and individual preferences of
a group of international experts and their institutions. The
suitability of individual professional groups (i.e. nurse practi-
tioners, nurse anaesthetists, anaesthesia assistants, and
physicians) to administer anaesthetic care for ERCP was not
within the scope of this project.
Methods
A modified Delphi approach was used to develop guidance on
the anaesthetic management of patients undergoing ERCP.
The modified Delphi technique as the method of building a
consensus was chosen, as there was not enough validated
literature available discussing the most reliable types of
anaesthesia for ERCP stratified based on patient comorbidities.
The modified Delphi approach is a validated and structured
group consensus strategy to obtain expert consensus9,10 that
uses multiple iterations to review expert judgement and reach
agreement.11 Each iteration modifies the survey to incorporate
feedback from the previous round until a consensus emerges.
It has the advantage of avoiding the influence of dominant
individuals or group pressure for conformity. The Delphi
approach is well suited for situations with limited evidence or
outcome data, and it relies on the collective expertise of group
members to increase content validity.12
A panel of 12 experts was selected to attain an expert
consensus regarding relevant patient management questions
(Supplementary Tables S1 and S2). An expert was defined as
an individual (attending/consultant level or equivalent quali-
fication) with extensive experience and expertise as an
anaesthesiologist or gastroenterologist in interventional
endoscopy. Although the optimal panel size of a Delphi survey
is unknown, a reasonable result can be obtained with panels of
10e15 experts.10
Our modified Delphi approach consisted of expert panel
participant selection, discussion of topic domains leading to
questionnaire development, and planning for online distri-
bution. The methodology was modified to conform closely to
Conducting and REporting of DElphi Studies (CREDES) guid-
ance on Delphi studies to ensure rigour and transparency in
conducting and reporting (https://www.equator-network.org/
reporting-guidelines/credes; Supplementary Table S3).
Definition of the broad question
In the initial stage, the research question was identified
(choice of general anaesthesia with tracheal intubation vs
deep sedation without tracheal intubation (monitored anaes-
thesia care). Moderate/light sedation, or ‘conscious sedation’,
where the patient is still able to respond purposefully to verbal
commands either with or without tactile stimulation,13,14 is
typically provided by non-anaesthesiologists15,16 and was not
considered by the panel. In contrast, under regulations, such
as those of the US Centers for Medicare & Medicaid Services,
monitored anaesthesia care typically requires deep sedation
and monitoring of the patient by a practitioner who is qualified
to administer anaesthesia.17
Definition of consensus
We defined agreement a priori as at least 75% of respondents
choosing ‘agree’/‘strongly agree’ or ‘strongly disagree’/
‘disagree’ responses in the online questionnaire iteration.
Questions with near consensus (55e74% agreement) were
discussed and decided on at the live face-to-face discussion
session. The experts also had the opportunity to change their
views regarding previously agreed topics in the live discus-
sion session. Once consensus was achieved on the questions,
the experts used literature summaries to generate, debate,
and refine a list of essential facts to guide the generation of
recommendations (Supplementary Table S6; Supplementary
Fig. S1).
Study conduct
During the Delphi process, we categorised the proposed
analysis into five task forces who presented their results to
the panellists at three meetings to receive feedback. During
Round 1, a comprehensive literature review was presented.
The voting members provided feedback on relevance, and
the panellists used these data to select four main topics to be
 General anaesthesia vs monitored anaesthesia care for ERCP - 765

addressed in the study within the area of the panellists’
expertise. In Round 2, 80 multiple-choice questions were
presented and then revised based on the results of a Survey
Monkey sent to all the panellists. In Round 3, topics with near
consensus (55e74%) were discussed to finalise the
guidelines.
Figure 1 includes a detailed flow chart of the stages of the
modified Delphi process, including a preparation phase, the
actual modified ‘Delphi rounds’, interim steps of data pro-
cessing and analysis, and concluding steps. More details on
the study conduct can be found in Supplementary Table S3. All
informational material in this modified Delphi process was
made available to all authors through a shared Google Drive.
The results of the survey were sent to all authors by e-mail and
were also available in PDF format on the shared Google Drive.
There was no deviation from the planned methodology. To

Preparation phase

Establish criteria for panel State the broad question

Select and invite panel members
members by a monitor (live session)

Implementation process

Round 1

Identify task force domains and Send topics within each domain to Summarise and refine
included members all panel members and get input questions (live session)

Round 2

Send refined questions to all Receive feedback and

panel members primary conclusion of results

Round 3

Discuss and revise results Summarise and categorise the

(live session) conclusions

Consensus and recommendation phase

Review and finalise consensus Review and finalise consensus Review and finalise consensus
Statement 1 Statement 2 Statement 3

Fig 1. Study flow of the modified Delphi process. There were three rounds of face-to-face online meetings during the modified Delphi
process. There was also communication through e-mails, and panellists revised documents shared online. Online feedback was anony-
mised, but the face-to-face meetings were not. The response rate of the online rounds was >91%. During the distribution of multiple
questions, weekly e-mails were sent out to remind the experts to respond. Round 1: a comprehensive literature review was conducted, and
studies were summarised in a document sent to voting members. The panellists were then invited to create a list of four topics within their
area of expertise. These selected topics were subsequently reviewed during an online live face-to-face session, in which topics that were
considered not clinically relevant by the panel members were eliminated. Round 2: 80 multiple-choice questions were created and refined
within each task force and then distributed through Survey Monkey to all the panellists. The panel then scored these questions, first
anonymously in writing by each member, then in an open discussion in light of the answers of the panels. Round 3: topics with near
consensus (55e74%) were discussed in the third live session. Those with scores <55% were not further discussed unless a panellist felt
strongly that a specific question had to be addressed. The latter was the case for the effects of age and ASA physical status score on
anaesthesia management, which were included in the discussion despite the absence of consensus. Consensus decision: based on the
topics upon which a consensus could be built in Round 3, three final categories were created, which centred the consensus document
(respiratory related, haemodynamic related, and procedural risks). The consensus statements were then written for these topics and
discussed individually with the panellists.
 766 - Azimaraghi et al.
prevent bias, two non-voting members (OA and KW), who
were independent members of the team, coordinated the
modified Delphi process.
Results
Main topic 1: risk of intraoperative or postoperative
respiratory adverse events
Consensus statement
The risk of intraprocedural hypoxaemia, hypercapnia,
and apnoea is greater with monitored anaesthesia care
compared with general anaesthesia with tracheal
intubation. However, when properly treated by the
anaesthetist, apnoea/hypopnea-associated events
might not translate to an increased risk of post-
operative complications.
Results and summary of evidence
The expert panel agreed that a higher rate of hypoxaemia
requiring airway manoeuvres occurs in anaesthetised patients
without a tracheal tube. This conclusion is supported by an
RCT evaluating general anaesthesia vs monitored anaesthesia
care.18
The expert panel agreed that monitored anaesthesia care is
preferable to general anaesthesia with tracheal intubation in
patients with chronic obstructive pulmonary disease (COPD)
or asthma.
There were differing opinions amongst the experts on the
differential risks of monitored anaesthesia care vs general
anaesthesia in patients with obstructive sleep apnoea (OSA).
Patients with an OSA diagnosis have a higher risk of
perioperative complications mainly because of their comor-
bidities (obesity and obesity hypoventilation syndrome).
However, it is unclear whether the diagnosis of OSA is an in-
dependent risk factor of postoperative respiratory
complications.19e21
The panel agreed that the decision of monitored anaes-
thesia care vs general anaesthesia in patients with OSA should
be based on individual and institutional experience. Patients
with OSA often have comorbidities that need to be carefully
considered by the anaesthetist.
Best practice recommendation
Monitored anaesthesia care increases the risk of intra-
operative apnoea more than general anaesthesia, but this
expected condition can be successfully treated by the anaes-
thetist. Avoiding tracheal intubation during ERCP has benefi-
cial effects, particularly in patients with severe COPD or
asthma.
Main topic 2: risk of intraoperative and postoperative
cardiovascular adverse events
Consensus statement
Risks of hypotension and reduced cardiac output are
greater during general anaesthesia compared with
monitored anaesthesia care.
Results and summary of evidence
The expert panel agreed that a higher rate of clinically
meaningful hypotension requiring vasopressor treatment oc-
curs during general anaesthesia compared with monitored
anaesthesia care. This is supported by a large observational
study that showed that hypotension occurred in 59% of pa-
tients undergoing general anaesthesia for ERCP compared
with 14% of patients undergoing monitored anaesthesia
care.4,18,22 The enhanced haemodynamic stability with moni-
tored anaesthesia care vs general anaesthesia might be
magnified when ERCP is conducted in the prone position
where an increased vulnerability to impaired venous return
exists.23,24
The panellists agreed that unstable coronary syndrome,
including unstable or severe angina or recent myocardial
infarction, is a predictor of increased perioperative cardio-
vascular risk. It was discussed that a decrease in arterial
pressure can lead to a critical decrease in coronary artery
blood flow, and that monitored anaesthesia care, compared
with general anaesthesia, is associated with lower risk of
procedural hypotension.25 Panellists also discussed that high
sympathetic tone (as a consequence of inadequate pain con-
trol during monitored anaesthesia care) can increase afterload
and risk of tachycardia, both of which increase myocardial
oxygen demand.26,27
Best practice recommendation
The expert panel concluded that monitored anaesthesia care
is preferred to general anaesthesia for ERCP in patients with
recent diagnosis of myocardial infarction or severe heart
failure.
Main topic 3: procedural risks and quality metrics
Consensus statement
Short ERCP procedures of low complexity should pref-
erably be conducted under monitored anaesthesia care
compared with general anaesthesia.
Results and summary of evidence
The panel agreed that the majority of short ERCP procedures of
low complexity can be conducted under monitored anaes-
thesia care. However, there are clinical scenarios defined
based on procedure type, provider experience, and patient
comorbidities, where general anaesthesia with tracheal intu-
bation is the preferred anaesthetic technique for ERCP.
Although no study has compared aspiration risk during
ERCP between general anaesthesia and monitored anaesthesia
care, the panel concluded that aspiration risk is higher during
monitored anaesthesia care, an assumption supported by
others.28,29
Further, the panel concluded that the increased risk of
aspiration with monitored anaesthesia care is greater in pa-
tients with comorbidities that increase their vulnerability to
aspiration. Taking into account aspiration risk during moni-
tored anaesthesia care, the expected duration of ERCP should
be considered, which depends on provider experience, pro-
cedure type, and the patient’s pathological anatomy. ERCP
 General anaesthesia vs monitored anaesthesia care for ERCP - 767

Monitored
anaesthesia care preferred
Procedural Patients high Patient
factors Short risk of PONV factors
procedures (100%)
allowing for
rapid patient Low ejection fraction,
recovery (91%) recent myocardial
infarction (83%)

Low arterial blood pressure

Experienced (75%)
anaesthesiologists (83%)
Chronic obstructive pulmonary

monitored anaesthesia care

Institutional experience with
disease, asthma (75%)

Diagnostic procedures (83%) Elderly patients (67%), ASA t3

(67%)

Procedures with high Stomach / oesophagus not empty

gastrointestinal bleeding risk, (91%)
abscess drainage
(75%) (ASGE IV) Aspiration risk/procedure
conducted in supine
Prolonged procedures position (91%)
with risk of hypoventilation,
perforation risk
Risk of respiratory
(pneumoperitoneum) –
failure/pre-existing
increased abdominal
hypoxia or
pressure (100%)
respiratory
Gastric outlet failure
obstruction (100%)
with risk
of aspiration
(ASGE IV) General anaesthesia preferred
100%)

Fig 2. Monitored anaesthesia care vs general anaesthesia in patients undergoing ERCP: decision support criteria. A modified Delphi
method was used to aggregate opinions from the panel of experts. The panel was asked to vote on how different procedural and patient-
related factors affect their decision in choosing between monitored anaesthesia care and general anaesthesia. Anonymous responses
were shared with the group and discussed to reach the best response through consensus. The decision to perform monitored anaes-
thesia care or general anaesthesia with tracheal intubation depends on procedural and patient characteristics. In addition, both the
experience of the anaesthetist and the institution need to be considered. In patients with haemodynamic instability, use of monitored
anaesthesia care is preferred, whereas patients with pre-procedural respiratory failure might have a lower anaesthesia risk with tracheal
intubation. Monitored anaesthesia care is preferred for short procedures to facilitate rapid patient recovery, whereas long interventional
procedures accompanied by increased risk of pulmonary aspiration and bleeding should be conducted with tracheal intubation. The
level of agreement amongst the expert panel is provided as per cent. The direction of the arrows indicates the expert panel final
recommendation. ASGE IV, American Society for Gastrointestinal Endoscopy Level IV procedures (e.g. endoscopic ultrasound-guided
trans-luminal access/drainage; ERCP in patients with concurrent gastric outlet obstruction; endoscopic ultrasound-guided chol-
edochoduodenostomy, cholecystogastrostomy, or cholecystoduodenostomy); ERCP, endoscopic retrograde cholangiopancreatography;
PONV, postoperative nausea and vomiting.

procedures of long duration might be better conducted under
general anaesthesia (Fig. 2).
ERCP complexity is graded by the American Society for
Gastrointestinal Endoscopy (ASGE) on a 4-point rating scale
(Supplementary Table S4).30 The panellists concluded that
monitored anaesthesia care can be used safely in patients
undergoing procedures with complexity Level I or II in the
ASGE categorisation. However, general anaesthesia should be
considered for ERCP procedures with complexity Level III or IV.
For example, removal of small stones is graded by ASGE as
complexity Level II, whereas large stone removal is graded as
complexity Level III.30 Similarly, the complexity of biliary
stricture treatment depends on localisation (extra-hepatic:
complexity II) and mechanism of the stricture (benign stric-
tures: complexity III). The panel discussed that these proced-
ures usually pose low risk of aspiration, perforation, and
bleeding,31 and hence can be done under monitored anaes-
thesia care. Similarly, diagnostic endoscopic ultrasound and
 768 - Azimaraghi et al.
endoscopic ultrasound with fine needle aspiration/biopsy of
adjacent structures represent complexity Levels I and II and
can be safely conducted under monitored anaesthesia care. In
these procedures of complexity Levels IeIII, there is no evi-
dence to suggest that rates of procedure-related adverse
events (bleeding, perforation, cholangitis, infection, pancrea-
titis, etc.) are higher with monitored anaesthesia care vs gen-
eral anaesthesia.
Intestinal perforation can lead to significant pneumo-
peritoneum, which can be better managed under general
anaesthesia (or might require monitored anaesthesia care to
be converted to general anaesthesia).32,33 The panel concluded
that although most endoscopic perforations can be immedi-
ately managed by endoscopists, their repair significantly in-
creases the duration of the procedure, as bleeding often occurs
and can lead to haemodynamic instability and possible blood
transfusion. Examples of such procedures are (ASGE
complexity Level IV) endoscopic ultrasound-guided trans-
luminal access/drainage; ERCP in patients with concurrent
gastric outlet obstruction; and endoscopic ultrasound-guided
choledochoduodenostomy, cholecystogastrostomy, or
cholecystoduodenostomy.30
Intestinal perforation can occur in about 10% of patients
undergoing endoscopic ultrasound-guided gastro-
jejunostomy,34 which can also lead to stent misemployment
into the peritoneal space and the need for its retrieval. In pa-
tients undergoing endoscopic ultrasound-guided cysto-enter-
ostomy for pancreatic pseudocysts and walled-off necrosis,
there is usually a large amount of fluid that drains into the
stomach immediately after the procedure, which significantly
increases the risk of aspiration.
The panel discussed that another example of a procedure
with increased risk of pulmonary aspiration is ERCP in patients
with gastric outlet obstruction. This procedure poses signifi-
cant risk of aspiration and often needs complex interventions
for the procedure to be successful. These include placement of
duodenal stent, pyloric or duodenal dilation, or endoscopic
ultrasound-guided transmural access of the biliary tree.
The panel considers that procedural risks need to be
interpreted in conjunction with the patient position during
the case.35e37 Although no controlled studies exist, the panel
concluded that the risk of aspiration during monitored
anaesthesia care is lower in the prone position compared
with in the supine position. In patients who undergo general
anaesthesia, the prone position probably does not decrease
the aspiration risk but rather adds time and risks related to
the change in positioning from prone to supine.38,39 The
panel considers that the optimal position (prone or supine)
depends on the procedure and institutional and provider
experience.
The panellists agreed that general anaesthesia increases
the risk of admission to the PACU, PACU length of stay,
nursing staff workload, and higher hospital costs. In compar-
ison, monitored anaesthesia care was considered to lead to
faster and better recovery after ERCP.
The panellists also agreed that facility-specific consider-
ations are important determinants in choosing between
monitored anaesthesia care and general anaesthesia in line
with previous studies.40e42 Higher turnover rates were agreed
to occur in institutions with preference for monitored anaes-
thesia care.
The panellists emphasised that endoscopy suite efficiency
is a complex topic that includes provider skills and institution
culture, whereas anaesthesia technique has a lower impact.
Thus, only six out of the initial 19 quality metric-related
questions were included in the final paper.
There was no consensus on quality metrics, such as pro-
cedural failure rates, patient satisfaction, post-ERCP pancrea-
titis, complication rates (perforation, bleeding, and
cholangitis), ERCP-related cardiopulmonary adverse events,
hospital re-admission, or adverse discharge.
Best practice recommendation
General anaesthesia is preferred in procedures that carry an
increased complication risk (aspiration and massive bleeding),
endoscopic ultrasound-guided trans-luminal access/drainage,
ERCP with concurrent gastric outlet obstruction, prolonged
cases with high procedural complexity, and massive post-
sphincterotomy bleeding.
Discussion
Evidence on the use of monitored anaesthesia care vs general
anaesthesia for ERCP is limited. We assessed in a controlled
manner the best practical and evidence-based insights from a
panel of expert anaesthesiologists and endoscopists. Using a
modified Delphi approach, we created a framework to
approach patients undergoing ERCP and to lay the foundation
for future research. Randomised controlled studies are needed
to examine the effects of predictor variables identified in this
study on ERCP-specific outcomes. Predictor variables include
patient comorbidities, procedure-specific characteristics, and
provider and institutional experience.
Respiratory adverse events
An important goal during ERCP is to minimise the risk of
clinically relevant periprocedural respiratory complications
and intraoperative desaturations. A randomised trial studying
200 subjects reported fewer transient desaturations during
procedures with general anaesthesia vs monitored anaes-
thesia care, which is of unclear clinical importance.18 Proce-
dural efficiency is likely lower with general anaesthesia, which
translates to increased healthcare utilisation and costs of
care.18 It is unknown if transient intraoperative hypoxaemia
translates to meaningful postoperative adverse out-
comes.40,43,44 Moderate intraoperative haemoglobin desatu-
ration can be treated successfully with airway interventions
(e.g. jaw thrust or increased oxygen supplementation, or both)
and does not necessitate discontinuation of the ERCP pro-
cedure. Observational studies also suggest that respiratory
sedation-related adverse events (SRAEs) are not significantly
associated with relevant outcomes, such as hospital length of
stay or adverse discharge to a nursing facility.22,45
Patients with increased airway reactivity are vulnerable to
reflex bronchoconstriction in response to tracheal intubation.
In a large retrospective study of 17 538 patients undergoing
ERCP from 2007 through 2018, 91% of patients with a previous
diagnosis of COPD received monitored anaesthesia care. No
association between intraprocedural hypoxaemia and adverse
discharge was reported in patients with a COPD diagnosis.22
This supports the safety of monitored anaesthesia care for
ERCP procedures in patients with COPD, whereas tracheal
intubation increases vulnerability to life-threatening
bronchospasm.46,47
Anaesthesiologists can manage patients with a diagnosis of
OSA well,48,49 but tracheal intubation can be more difficult in
subgroups of patients with OSA. This might favour use of
 General anaesthesia vs monitored anaesthesia care for ERCP
monitored anaesthesia care as long as emergent intubation
can be avoided. Postoperatively, respiratory depressants, such
as opioids and benzodiazepines, should be avoided. Patients
with obesity hypoventilation syndrome have additional risk
when undergoing monitored anaesthesia care, as hypo-
ventilation cannot be compensated. In contrast, drugs used for
tracheal intubation, such as neuromuscular blocking drugs
and opioids, and even the tracheal intubation itself are risk
factors for respiratory complications.50,51
There is no current standard of care to guide the choice on
monitored anaesthesia care vs general anaesthesia for ERCP.
However, in patients with increased airway reactivity, such as
COPD or asthma, monitored anaesthesia care might be supe-
rior to general anaesthesia.46,47
Cardiovascular adverse events
Hypotension occurs frequently in patients undergoing general
anaesthesia for ERCP. Post-intubation hypotension is usually
attributable to anaesthetic-induced vasodilation and
increased intrathoracic pressure during positive-pressure
ventilation, which leads to diminished central venous blood
return and cardiac filling pressures.52e54
Hypotension, with MAP <55 mm Hg, has been reported as
an independent risk factor for poor outcomes in patients un-
dergoing monitored anaesthesia care and general anaes-
thesia.55e58 Patients undergoing general anaesthesia are more
vulnerable to intraoperative hypotension compared with
those who receive monitored anaesthesia care for ERCP. This
can be explained by the haemodynamic and respiratory side-
effects of general anaesthetics. Propofol and other gamma-
aminobutyric acid (GABA)-ergic anaesthetics induce dose-
dependent arterial hypotension through vasodilation. Moni-
tored anaesthesia care typically requires lower doses of these
anaesthetics than general anaesthesia, such that hypotension
is less likely or severe.59,60
During the transition from spontaneous (negative intratho-
racic pressure) breathing to positive-pressure ventilation,
venous return and cardiac filling pressures decrease. Positive
intrathoracic pressure leads to hypotension even in the absence
of anaesthetic-induced vasodilation.61,62 The risk of general
anaesthesia-associated arterial hypotension is magnified in
patients with latent hypovolaemia (tachycardia and normo-
tension), patients with morbid obesity who might be given
higher doses of anaesthetics and need higher airway pressures,
and those who need higher plateau pressure to achieve the
desired tidal volume during mechanical ventilation.62,63
General anaesthesia and tracheal intubation also increase
vulnerability to vasovagal syncope, a cardiovascular reflex
caused by increased vagal tone secondary to carotid sinus
stimulation during direct laryngoscopy. The parasympathetic
activation and sympathetic inhibition can cause bradycardia
and hypotension, which can occur during tracheal intubation
and are magnified in the context of reduced cardiac venous
return, emotional stress, and pain.64,65
Adequate dosing of anaesthetics during general anaesthesia
can minimise increases in myocardial oxygen consumption as
a consequence of patient discomfort during ERCP, as long as
normal arterial pressure and heart rate are maintained.66,67
Procedural risks and quality metrics
Decisions about the optimal anaesthetic procedure for ERCP
cannot be exclusively based on patient comorbidities.
- 769
Procedural risks, which are the consequence of both the pro-
cedure itself and the skills and efficiency of the proceduralist,
also need to be considered.
A recent single-centre randomised clinical trial revealed
the importance of institutional culture in the selection of the
appropriate anaesthesia technique for ERCP. In this study,
29.2% of ERCP cases under monitored anaesthesia care needed
to be interrupted for chin lift and jaw trust.44 This is in contrast
to the experience of the panellists in their institutions, where
these airway manoeuvres are part of the usual practice during
the dynamic titration of propofol dose throughout the ERCP.
This emphasises the fact that specific skills and provider
training are required to implement a change from general
anaesthesia to monitored anaesthesia care.
For short procedures of low complexity, monitored anaes-
thesia care typically offers a faster turnover rate because in-
duction and recovery times are shorter, and there is no need
for Phase I recovery (time to attain pain control and stable
respiratory, haemodynamic, and neurological status).68,69
Additionally, the relative risk and discomfort associated with
tracheal intubation might not be balanced by clinical benefit in
long and difficult cases.
Two major procedural risks during ERCP are pulmonary
aspiration of gastric or oesophageal contents and gastroin-
testinal perforation, both of which affect respiratory function.
Aspiration during procedural sedation is rare, idiosyncratic,
and typically benign.69,70 During general anaesthesia, the risk
of aspiration is magnified during tracheal intubation and
extubation, whereas during monitored anaesthesia care
aspiration risk is elevated during insertion of the endo-
scope.71 Increased risk of aspiration must be expected in pa-
tients undergoing endoscopic ultrasound-guided access and
drainage of large fluid collections. The risk is greater in pa-
tients with food in the gastroesophageal space and in those
with gastric outlet obstruction related to pancreaticobiliary
pathology.33,41,72
Perbtani and colleagues73 evaluated the impact of general
anaesthesia on various efficiency metrics. In their study, 1421
patients who underwent 1635 interventional endoscopic pro-
cedures over a 6 month period were analysed based on various
procedural time stamps, such as anaesthesia ready time,
endoscopist ready time, procedure time, and room exit time.
Except for room turnover time, all other process efficiency
metrics were significantly prolonged amongst patients who
were tracheally intubated.28,73 Other quality indicators, such
as ‘frequency with which ERCP is performed for an appropriate
indication and documented’ and ‘rate of post-ERCP pancrea-
titis’, have been proposed as priority quality indicators in the
ERCP suite.40,42
Patient age and ASA physical status were not considered
strong determinants of choosing between monitored anaes-
thesia care and general anaesthesia. The ASA physical status
classification system was developed in 1941 to help assess and
communicate patients’ pre-anaesthesia medical comorbid-
ities.74 The classification system alone is neither intended to
be used in isolation to predict perioperative risk nor to deter-
mine choice of anaesthetic technique but should be used with
other factors, such as type and duration of surgery, emergency
status, etc.
Even though frail patients have a higher risk of
periprocedural complications, age is not a strong indicator
of frailty75 and is even less so in frail patients who are not fit for
surgery and therefore receive endoscopic interventions.75,76
 770 - Azimaraghi et al.
Limitations
The personal experiences of the experts could have influenced
the results. All experts had many years of practical experience
and are key opinion leaders in their international elite uni-
versities. In addition, the results from the last round were
discussed amongst contributors, including the research team
and external participants (colleagues).
Conclusions
The international expert panel concludes that monitored
anaesthesia care is the favoured anaesthesia plan for ERCP.
However, an individual riskebenefit analysis that takes into
account provider and institutional experience, patient
comorbidities, and procedural risks is needed for each case.
There are no universal quality metrics for provision of
anaesthesia for ERCP. Finally, the anaesthesia plan should also
be made based on institutional factors.
Authors’ contributions
Study concept/design: MBi, SA, MA, MBe, JLB, CC, PF, MSS, ES,
KL, ME
Data collection: OA
Data analysis: OA, KL, ME
Data interpretation: OA, MBi, SA, MA, MBe, JLB, CC, PF, MSS, ES,
KW, KL, ME
Drafting of paper: OA, KL, ME
Critical revision of paper: OA, MBi, SA, MA, MBe, JLB, CC, PF,
MSS, ES, KW, KL, ME
All authors approved the final paper to be published and agree
to be accountable for all aspects of the work, ensuring that
questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved.
Acknowledgements
The authors would like to thank Robert Ross, Tracey Straker,
Irene Osborn, Thomas Ulman, Sammy Ho, Peter Santer,
Jonathan Leff, Sujatha Ramachandran, Maximilian Schaefer,
Maira I. Rudolph, Aiman Suleiman, and Annika S. Witt, who
contributed to this project.
Declaration of interest
KL is an editor and ME is a member of the associate editorial
board of the British Journal of Anaesthesia. The other authors
have no conflicts of interest.
Funding
This study was supported by an unrestricted donation to
Matthias Eikermann by Jeff and Judy Buzen. The donors did
not have an influence on design of the study, interpretation of
results, or writing the manuscript.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.bja.2023.03.012.
References
1. Huang RJ, Barakat MT, Girotra M, Lee JS, Banerjee S. Un-
planned hospital encounters after endoscopic retrograde
cholangiopancreatography in 3 large North American
states. Gastroenterology 2019; 156: 119e129.e3
2. Chandrasekhara V, Khashab MA, Muthusamy VR, et al.
Adverse events associated with ERCP. Gastrointest Endosc
2017; 85: 32e47
3. Hormati A, Aminnejad R, Saeidi M, Ghadir MR,
Mohammadbeigi A, Shafiee H. Prevalence of anesthetic
and gastrointestinal complications of endoscopic retro-
grade cholangiopancreatography. Anesth Pain Med 2019; 9,
e95796
4. Berzin TM, Sanaka S, Barnett SR, et al. A prospective
assessment of sedation-related adverse events and pa-
tient and endoscopist satisfaction in ERCP with
anesthesiologist-administered sedation. Gastrointest
Endosc 2011; 73: 710e7
5. Liu H, Waxman DA, Main R, Mattke S. Utilization of
anesthesia services during outpatient endoscopies and
colonoscopies and associated spending in 2003-2009.
JAMA 2012; 307: 1178e84
6. Cohen LB, Wecsler JS, Gaetano JN, et al. Endoscopic
sedation in the United States: results from a nationwide
survey. Am J Gastroenterol 2006; 101: 967e74
7. Henriksson AM, Thakrar SV. Anaesthesia and sedation for
endoscopic retrograde cholangiopancreatography. BJA
Educ 2022; 22: 372e5
8. Gatley SJ, Gifford AN, Volkow ND, Lan R, Makriyannis A.
123I-labeled AM251: a radioiodinated ligand which binds
in vivo to mouse brain cannabinoid CB1 receptors. Eur J
Pharmacol 1996; 307: 331e8
9. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA
appropriateness method user’s manual 2001. Available
from https://www.rand.org/content/dam/rand/pubs/
monograph_reports/2011/MR1269.pdf. Accessed: 1
January 2001.
10. Diamond IR, Grant RC, Feldman BM, et al. Defining
consensus: a systematic review recommends methodo-
logic criteria for reporting of Delphi studies. J Clin Epidemiol
2014; 67: 401e9
11. Makhmutov R. The Delphi method at a glance. Pflege 2021;
34: 221
12. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C.
Using and reporting the Delphi method for selecting
healthcare quality indicators: a systematic review. PLoS
One 2011; 6, e20476
13. Safe sedation practice for healthcare procedures. An up-
date. https://www.aomrc.org.uk/wp-content/uploads/
2021/02/Safe_sedation_practice_for_healthcare_
procedures_update_0521.pdf. Accessed: February 2021.
14. Continuum of Depth of Sedation: Definition of General
Anesthesia and Levels of Sedation/Analgesia. https://
www.asahq.org/standards-and-guidelines/continuum-of-
depth-of-sedation-definition-of-general-anesthesia-and-
levels-of-sedationanalgesia. Accessed: 23 October 2019.
15. Healthy Blue. CG-MED-21 anesthesia services and mod-
erate (“conscious”) sedation 2023. Available from https://
provider.healthybluesc.com/dam/medpolicies/
healthybluesc/active/guidelines/gl_pw_a050123.html.
Accessed: 4 January 2023.
 General anaesthesia vs monitored anaesthesia care for ERCP
16. American Society of Anesthesiologists. Statement on
granting privileges for administration of moderate seda-
tion to practitioners who are not anesthesia professionals
2021. Available from https://www.asahq.org/standards-
and-guidelines/statement-of-granting-privileges-for-
administration-of-moderate-sedation-to-practitioners.
Accessed: 13 October 2021.
17. Baltimore MD. CMS manual system: pub. 100e07 state oper-
ations provider certification 2010. Available from http://
www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/downloads//R59SOMA.pdf. [Accessed 21
May 2010]
18. Smith ZL, Mullady DK, Lang GD, et al. A randomized
controlled trial evaluating general endotracheal anes-
thesia versus monitored anesthesia care and the inci-
dence of sedation-related adverse events during ERCP in
high-risk patients. Gastrointest Endosc 2019; 89: 855e62
19. American Society of Anesthesiologists. Practice guidelines
for the perioperative management of patients with
obstructive sleep apnea: an updated report by the Amer-
ican Society of Anesthesiologists task force on perioper-
ative management of patients with obstructive sleep
apnea. Anesthesiology 2014; 120: 268e86
20. Santer P, Eikermann M. Unrecognized obstructive sleep
apnea in patients undergoing surgery. JAMA 2019; 322:
1211
21. Dandrieu MR, Brood-van Zanten MM. Isoxsuprine in
nonproliferative diabetic retinopathy: effect on human
retinal circulation assessed by fluorescein angiographyda
pilot study. Angiology 1991; 42: 140e5
22. Althoff FC, Agnihotri A, Grabitz SD, et al. Outcomes after
endoscopic retrograde cholangiopancreatography with
general anaesthesia versus sedation. Br J Anaesth 2021;
126: 191e200
23. Sudheer PS, Logan SW, Ateleanu B, Hall JE. Haemody-
namic effects of the prone position: a comparison of
propofol total intravenous and inhalation anaesthesia.
Anaesthesia 2006; 61: 138e41
24. Terruzzi V, Radaelli F, Meucci G, Minoli G. Is the supine
position as safe and effective as the prone position for
endoscopic retrograde cholangiopancreatography? A
prospective randomized study. Endoscopy 2005; 37: 1211e4
25. Sacks D, Baxter B, Campbell BCV, et al. Multisociety
consensus quality improvement revised consensus
statement for endovascular therapy of acute ischemic
stroke. Int J Stroke 2018; 13: 612e32
26. Crystal GJ, Pagel PS. Right ventricular perfusion: physi-
ology and clinical implications. Anesthesiology 2018; 128:
202e18
27. Duncker DJ, Bache RJ. Regulation of coronary blood flow
during exercise. Physiol Rev 2008; 88: 1009e86
28. Janik LS, Stamper S, Vender JS, Troianos CA. Pro-Con
debate: monitored anesthesia care versus general endo-
tracheal anesthesia for endoscopic retrograde chol-
angiopancreatography. Anesth Analg 2022; 134: 1192e200
29. Garewal D, Vele L, Waikar P. Anaesthetic considerations
for endoscopic retrograde cholangio-pancreatography
procedures. Curr Opin Anaesthesiol 2013; 26: 475e80
30. Cotton PB, Eisen G, Romagnuolo J, et al. Grading the
complexity of endoscopic procedures: results of an ASGE
working party. Gastrointest Endosc 2011; 73: 868e74
31. Andriulli A, Loperfido S, Napolitano G, et al. Incidence
rates of post-ERCP complications: a systematic survey of
prospective studies. Am J Gastroenterol 2007; 102: 1781e8
- 771
32. Pisipati S, Thoguluva Chandrasekar V, Faigel DO,
Fukami N, Pannala R. Emphysematous cholangitis with
pneumoperitoneum at ERCP. Gastrointest Endosc 2021; 94:
860e2
33. Jafari Chokan NM, Pishbin E, Farhadi A, Reihani H. Ten-
sion pneumoperitoneum: a rare complication after endo-
scopic retrograde cholangiopancreatography. J Emerg Med
2017; 53: 914e5
34. Forbes N, Coelho-Prabhu N, Al-Haddad MA, et al. Adverse
events associated with EUS and EUS-guided procedures.
Gastrointest Endosc 2022; 95: 16e26.e2
35. Mashiana HS, Jayaraj M, Mohan BP, Ohning G, Adler DG.
Comparison of outcomes for supine vs. prone position
ERCP: a systematic review and meta-analysis. Endosc Int
Open 2018; 6: E1296e301
36. Osagiede O, Bolan ~ os GA, Cochuyt J, et al. Impact of supine
versus prone position on endoscopic retrograde chol-
angiopancreatography performance: a retrospective
study. Ann Gastroenterol 2021; 34: 582e7
37. Varma P, Ket S, Paul E, et al. Does ERCP position matter? A
randomized controlled trial comparing efficacy and com-
plications of left lateral versus prone position (POSITION
study). Endosc Int Open 2022; 10: E403e12
38. Channabasappa SM, Shankarnarayana P. A comparative
study of hemodynamic changes between prone and su-
pine emergence from anesthesia in lumbar disc surgery.
Anesth Essays Res 2013; 7: 173e7
39. Parker JD. Pulmonary aspiration during procedural seda-
tion for colonoscopy resulting from positional change
managed without oral endotracheal intubation. JA Clin Rep
2020; 6: 53
40. Smith ZL, Das KK, Kushnir VM. Anesthesia-administered
sedation for endoscopic retrograde cholangiopancreatog-
raphy: monitored anesthesia care or general endotracheal
anesthesia? Curr Opin Anaesthesiol 2019; 32: 531e7
41. Ozgonul A, Cece H, Sogut O, Demir D, Kurkcuoglus IC.
Pneumoperitoneum, pneumoretroperitoneum and bilat-
eral pneumothorax caused by ERCP. J Pak Med Assoc 2010;
60: 60e1
42. Adler DG, Lieb 2nd JG, Cohen J, et al. Quality indicators for
ERCP. Gastrointest Endosc 2015; 81: 54e66
43. Vargo 2nd JJ. Sedation-related complications in gastroin-
testinal endoscopy. Gastrointest Endosc Clin N Am 2015; 25:
147e58
44. Alzanbagi AB, Jilani TL, Qureshi LA, et al. Randomized trial
comparing general anesthesia with anesthesiologist
administered deep sedation for ERCP in average-risk pa-
tients. Gastrointest Endosc 2022; 96: 983e990.e2
45. Smith ZL, Nickel KB, Olsen MA, Vargo JJ, Kushnir VM. Type
of sedation and the need for unplanned interventions
during ERCP: analysis of the clinical outcomes research
initiative national endoscopic database (CORI-NED).
Frontline Gastroenterol 2020; 11: 104e10
46. Silvanus MT, Groeben H, Peters J. Corticosteroids and
inhaled salbutamol in patients with reversible airway
obstruction markedly decrease the incidence of bron-
chospasm after tracheal intubation. Anesthesiology 2004;
100: 1052e7
47. Xu CX, Chen X, Jia Y, et al. Stepwise sedation for elderly
patients with mild/moderate COPD during upper gastro-
intestinal endoscopy. World J Gastroenterol 2013; 19: 4791e8
48. Fassbender P, Herbstreit F, Eikermann M, Teschler H,
Peters J. Obstructive sleep apneada perioperative risk
factor. Dtsch Arztebl Int 2016; 113: 463e9
 772 - Azimaraghi et al.
49. Szeto B, Vertosick EA, Ruiz K, et al. Outcomes and
safety among patients with obstructive sleep apnea
undergoing cancer surgery procedures in
freestanding ambulatory surgical facility. Anesth Analg
2019; 129: 360e8
50. Kirmeier E, Eriksson LI, Lewald H, et al. Post-anaesthesia
pulmonary complications after use of muscle relaxants
(POPULAR): a multicentre, prospective observational
study. Lancet Respir Med 2019; 7: 129e40
51. Hammer M, Santer P, Schaefer MS, et al. Supraglottic
airway device versus tracheal intubation and the risk of
emergent postoperative intubation after general anaes-
thesia in adults: a retrospective cohort study. Br J Anaesth
2021; 126: 738e45
52. Soni N, Williams P. Positive pressure ventilation: what is
the real cost? Br J Anaesth 2008; 101: 446e57
53. Mitaka C, Nagura T, Sakanishi N, Tsunoda Y, Amaha K.
Two-dimensional echocardiographic evaluation of inferior
vena cava, right ventricle, and left ventricle during positive-
pressure ventilation with varying levels of positive end-
expiratory pressure. Crit Care Med 1989; 17: 205e10
54. Pinsky MR. Cardiovascular issues in respiratory care. Chest
2005; 128: 592Se7s
55. Wachtendorf LJ, Azimaraghi O, Santer P, et al. Association
between intraoperative arterial hypotension and post-
operative delirium after noncardiac surgery: a retrospec-
tive multicenter cohort study. Anesth Analg 2022; 134:
822e33
56. Davis MJ, Menon BK, Baghirzada LB, et al. Anesthetic
management and outcome in patients during endovas-
cular therapy for acute stroke. Anesthesiology 2012; 116:
396e405
57. Whalin MK, Lopian S, Wyatt K, et al. Dexmedetomidine: a
safe alternative to general anesthesia for endovascular
stroke treatment. J Neurointerv Surg 2014; 6: 270e5
58. Whalin MK, Halenda KM, Haussen DC, et al. Even small
decreases in blood pressure during conscious sedation
affect clinical outcome after stroke thrombectomy: an
analysis of hemodynamic thresholds. Am J Neuroradiol
2017; 38: 294e8
59. McCarty TR, Hathorn KE, Creighton DW, AlSamman MA,
Thompson CC. Safety and sedation-associated
adverse event reporting among patients undergoing
endoscopic cholangiopancreatography: a comparative
systematic review and meta-analysis. Surg Endosc 2021;
35: 6977e89
60. Jacobson BC, Carr-Locke DL. Hypotension during ERCP is
common but not a risk factor for post-ERCP pancreatitis.
HPB (Oxford) 2001; 3: 169e73
61. Shekerdemian L, Bohn D. Cardiovascular effects of me-
chanical ventilation. Arch Dis Child 1999; 80: 475e80
62. Manthous CA. Avoiding circulatory complications during
endotracheal intubation and initiation of positive pres-
sure ventilation. J Emerg Med 2010; 38: 622e31
63. Wadhwa V, Issa D, Garg S, Lopez R, Sanaka MR, Vargo JJ.
Similar risk of cardiopulmonary adverse events between
a propofol and traditional anesthesia for gastrointestinal
endoscopy: a systematic review and meta-analysis. Clin
Gastroenterol Hepatol 2017; 15: 194e206
64. Jeanmonod R, Sahni D, Silberman M. Vasovagal Episode.
[Updated 2023 Jan 31]. In: StatPearls [Internet]. Treasure Is-
land (FL): StatPearls Publishing; 2023 Jan. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470277/
65. Salvucci F, Leuzzi S, Calciati A, et al. [Vasovagal syncope].
Recenti Prog Med 1993; 84: 443e56
66. Bonney S, Hughes K, Eckle T. Anesthetic cardioprotection:
the role of adenosine. Curr Pharm Des 2014; 20: 5690e5
67. Chen K, Yu J, Wang Q, et al. The timing of propofol
administration affects the effectiveness of remote
ischemic preconditioning induced cardioprotection in
rats. J Cell Biochem 2020; 121: 4535e41
68. Togioka BM, Yanez D, Aziz MF, Higgins JR, Tekkali P,
Treggiari MM. Randomised controlled trial of sugamma-
dex or neostigmine for reversal of neuromuscular block
on the incidence of pulmonary complications in older
adults undergoing prolonged surgery. Br J Anaesth 2020;
124: 553e61
69. Green SM, Mason KP, Krauss BS. Pulmonary aspiration
during procedural sedation: a comprehensive systematic
review. Br J Anaesth 2017; 118: 344e54
70. Hsieh TC, Wu YC, Ding HJ, et al. Clinically unrecognized
pulmonary aspiration during gastrointestinal endoscopy
with sedation: a potential pitfall interfering the perfor-
mance of 18F-FDG PET for cancer screening. Eur J Radiol
2011; 80: e510e5
71. Adachi K, Umezaki T, Kikuchi Y. Videoendoscopy worsens
swallowing function: a videofluoroscopic study. A ran-
domized controlled trial. Eur Arch Otorhinolaryngol 2017;
274: 3729e34
72. Schro € der AS, Heinemann A, Nushida H, Sperhake JP. Fatal
pneumoperitoneum following endoscopic retrograde
cholangiopancreatography confirmed by post-mortem
computed tomography. Forensic Sci Med Pathol 2015; 11:
460e3
73. Perbtani YB, Summerlee RJ, Yang D, et al. Impact of
endotracheal intubation on interventional endoscopy unit
efficiency metrics at a tertiary academic medical center.
Am J Gastroenterol 2016; 111: 800e7
74. Mayhew D, Mendonca V, Murthy BVS. A review of ASA
physical statusdhistorical perspectives and modern de-
velopments. Anaesthesia 2019; 74: 373e9
75. Wolf JH, Hassab T, D’Adamo CR, et al. Frailty is a stronger
predictor than age for postoperative morbidity in Crohn’s
disease. Surgery 2021; 170: 1061e5
76. Ukkonen M, Siiki A, Antila A, Tyrva € inen T, Sand J,
Laukkarinen J. Safety and efficacy of acute endoscopic
retrograde cholangiopancreatography in the elderly. Dig
Dis Sci 2016; 61: 3302e8
Handling editor: Hugh C Hemmings Jr