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HOME > Clin Endosc > Volume 58(6); 2025 > Article
Systematic Review and Meta-analysis Comparative efficacy and safety of supine versus prone positioning in endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis
Fariha Hasan1orcid, Muhammad Shahzil2orcid, Ayesha Liaquat3orcid, Taha Bin Arif4orcid, Muhammad Yafaa Naveed Chaudhary5orcid, Eugene Annor6orcid, Dushyant Singh Dahiya7orcid, Jay Patel8orcid, Rohini Maddigunta9orcid, Avneet Singh1orcid, Alexander Garcia1orcid, Babu P. Mohan10orcid, Rachel Frank8,9orcid, Adib Chaaya8,9orcid
Clinical Endoscopy 2025;58(6):843-853.
DOI: https://doi.org/10.5946/ce.2025.072
Published online: August 26, 2025

1Department of Internal Medicine, Cooper University Hospital, Camden, NJ, USA

2Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA

3Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan

4Department of Internal Medicine, Sinai Hospital Baltimore, Baltimore, MD, USA

5Department of Internal Medicine, Indiana University Southwest, New Albany, IN, USA

6Department of Internet Medicine, University of Illinois College of Medicine, Chicago, IL, USA

7Department of Gastroenterology & Hepatology, The University of Kansas School of Medicine, Kansas City, KS, USA

8Department of Gastroenterology, Cooper University Hospital, Camden, NJ, USA

9Cooper Medical School of Rowan University, Camden, NJ, USA

10Orlando Gastroenterology PA, Orlando, FL, USA

Correspondence: Rohini Maddigunta Cooper Medical School of Rowan University, 401 S. Broadway, Camden, NJ 08103, USA E-mail: maddig24@rowan.edu
• Received: March 5, 2025   • Revised: May 22, 2025   • Accepted: May 24, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background/Aims
    Endoscopic retrograde cholangiopancreatography (ERCP) is conventionally performed in the prone position (PP). Recent studies have shown that the supine position (SP) is an effective alternative, with comparable success rates. We conducted a meta-analysis to directly compare the safety and efficacy of the two ERCP positions.
  • Methods
    In line with Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed through a comprehensive search of PubMed, Embase, Web of Science, and the Cochrane Library. Statistical analyses were performed using RevMan, with results considered significant at p<0.05 and reported as odds ratios (ORs) and mean differences (MDs).
  • Results
    Eleven studies (24,285 patients) were included in the final analysis. Procedural success was significantly higher in the PP (OR, 0.52; 95% confidence interval [CI], 0.36–0.75; p<0.0004) than the SP. However, no significant difference was observed in procedure times (MD, 0.22; 95% CI, –7.07 to 7.50; p=0.95), number of cardiopulmonary complications (OR, 1.08; 95% CI, 0.47–2.48; p=0.86), or post-ERCP pancreatitis (OR, 1.12; 95% CI, 0.52–2.42; p=0.31) between the two groups.
  • Conclusions
    The PP demonstrates superior ERCP success compared to the SP, without prolonging procedure time or increasing the risk of adverse events. However, given the comparable procedure times, incidence of adverse events, and increased comfort for both patients and anesthesiologists, the SP may be a suitable alternative for a select group of patients in whom the PP is not feasible, such as those with morbid obesity or recent abdominal surgery.
  • Keywords: Endoscopic retrograde cholangiopancreatography; Meta-analysis; Pancreatitis; Prone position; Supine position; Therapeutic outcome
Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable for diagnosing and treating a wide array of pancreaticobiliary disorders.1 Despite its critical role in modern gastroenterology, ERCP is a technically demanding procedure with associated risks, including cholangitis, pancreatitis, bleeding, and anesthesia-related cardiopulmonary complications.2-4 The procedure’s success is closely linked to the skills of the endoscopist, patient anatomy, and the ease of bile duct cannulation-all of which are markedly influenced by patient positioning.4
Traditionally, ERCP is performed in the prone position (PP), a posture favored for facilitating deep biliary cannulation, optimal fluoroscopic imaging, and reduced aspiration risk.5,6 The PP offers technical advantages that contribute to higher success rates and shorter procedure durations, making it the preferred choice among endoscopists.1,7 However, patient conditions including morbid obesity, recent abdominal surgery, or specific anatomical challenges such as those observed with post-Billroth II gastrectomies necessitate alternative positioning, with the supine position (SP) emerging as a viable option.8,9
Although less commonly used in endoscopy suites owing to concerns about increased technical failures and higher rates of adverse events, the SP offers significant benefits in certain clinical scenarios. For instance, the SP is often preferred in patients requiring general anesthesia with endotracheal intubation, as it allows for better airway management and visualization of the complex biliary anatomy.10 Moreover, the SP can provide greater comfort for patients with limited cervical mobility or abdominal distension and for anesthesiologists who prioritize ease of monitoring during the procedure.6,10,11
Despite these advantages, data on the outcomes of ERCPs performed in the SP remain limited, with existing studies highlighting a compromise between the technical success rates and the incidence of adverse events. A previous study reported a slight preference for the PP, owing to its higher technical success rate and shorter procedural durations. However, these benefits are offset by an increased incidence of adverse events.10
To address the limitations of previous studies and incorporate newly published data, we conducted a head-to-head meta-analysis that directly compared the outcomes of the SP and PP during ERCP.
This meta-analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.12,13 Ethics approval was not required for this study.
Data sources and search strategy
A comprehensive electronic search was conducted across multiple databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Medline (via Ovid), Embase (Elsevier), and Web of Science, encompassing all records from inception to July 2024. The reference lists of the included studies and relevant systematic reviews were also screened. The search strategy utilized a combination of keywords and Medical Subject Headings terms, such as “Endoscopic Retrograde Cholangiopancreatography”, “Prone Position”, and “Supine Position”. The detailed search strategies are provided in Supplementary Table 1.
Eligibility criteria
Eligible studies included randomized-controlled trials (RCTs), prospective comparative studies, and observational studies (case-control, retrospective, or prospective cohort studies) involving patients undergoing ERCPs. The intervention group consisted of patients in the SP during ERCP, whereas the control group consisted of patients in the PP. No restrictions were applied regarding the geographical location or patient age. Studies were excluded if they were literature reviews, case reports, single-arm studies, case series with <10 patients, duplicate studies, or animal studies. Additionally, studies that lacked relevant data, addressed different endpoints, or did not directly compare the intervention with a control group were excluded.
Study selection and data extraction
Two reviewers (A.L. and M.S.) independently selected the studies and extracted the data, and contradictions were resolved by a third reviewer (F.H.). Duplicate records were removed using Mendeley Desktop 1.19.8. Data were extracted using a standardized form that captured information on study characteristics (e.g., authors and study design), patient demographics (e.g., age and sex), as well as primary and secondary outcomes.
Study definitions
Technical success was defined as successful cannulation of the desired duct or achievement of ERCP’s therapeutic and diagnostic goals.
Outcomes
The primary outcomes evaluated were technical success and mean procedure time. The secondary outcomes included the incidence of cardiopulmonary complications and post-ERCP pancreatitis (PEP).
Data analysis
The meta-analysis was performed using Review Manager (RevMan ver. 5.4; The Cochrane Collaboration). Dichotomous outcomes are expressed as odds ratios (ORs) with 95% confidence intervals (CIs), and continuous outcomes are presented as mean differences (MDs) with standard deviations and 95% CIs using the inverse variance method. Statistical significance was defined as p<0.05. Heterogeneity was assessed using the chi-squared test and Higgins I2 statistic, where I2 greater than 50% showed significance.14 Funnel plots were used to assess publication bias for outcomes with more than ten studies, whereas deviation from optimal intervention plots in MetaXL were used for outcomes with 3 to 10 studies. Sensitivity analyses were conducted on the primary outcomes by excluding studies with a high risk of bias and exploring the sources of heterogeneity.
Risk of bias and certainty-of-evidence assessment
The risk of bias in the included RCT was assessed using the revised Cochrane Risk of Bias Tool (RoB 2.0), implemented in RevMan ver. 5.4 which examined bias across five domains—randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result (Supplementary Fig. 1).15 For cohort studies with available full texts, the Newcastle-Ottawa Scale was used to assess the risk of bias (Supplementary Table 2).6,8,9,15-17 This scale evaluates studies based on eight criteria across three domains: selection of study groups, comparability, and ascertainment of exposure or outcome.18 Three criteria (demonstration that outcome of interest was not present at start of study, was follow-up long enough for outcomes to occur, and adequacy of follow-up of cohorts) that were not applicable to our studies were excluded, reducing the maximum possible score to six stars. The certainty of evidence for each outcome was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, considering factors such as study limitations, consistency of results, precision, directness, and publication bias. A summary of the GRADE findings is presented in Supplementary Table 3.19 Funnel plots were used for the qualitative analysis of publication bias and are depicted in Supplementary Figures 2–5.
Baseline study characteristics
From 1,055 studies, 812 records were screened after 243 duplicates were removed. Subsequently, 17 articles were assessed for eligibility. Ultimately, 11 original studies (7 prospective cohorts, three retrospective cohorts, and 1 RCTs) were included in the analysis.6,8,9,16,17,20-25 Of these, five were abstracts and six were full-text articles. A schematic of the study selection process is illustrated in Figure 1, and the study characteristics are presented in Table 1.6,8,9,16,17,20-25
The demographic characteristics and patient profiles of the included studies are summarized as follows: in total, 24,285 patients were included in the analysis, encompassing 24,358 ERCPs. Of these, 2,888 were performed in the SP and 21,470 in the PP. The mean patient age ranged from 56.9 to 69.9 years, with males constituting 44.7% and 52.3% of the SP and PP groups, respectively. Further details are presented in Table 2.6,8,9,16,17,20-25 The outcome data are presented in Table 3.6,8,9,16,17,20-25
Technical success
The data from ten studies (24,116 patients) that compared the technical success of ERCP between the PP and SP were pooled. Compared to the SP, the technical success rate was significantly higher in the PP (OR, 0.52; 95% CI, 0.36–0.75; p=0.0004). I2 was calculated as 37%, indicating low heterogeneity (Fig. 2).
Mean procedure times
The results from the seven studies (23,104 patients) comparing mean procedure times between the two groups were pooled together, and no statistically significant difference was observed between the two groups (MD, 0.22; 95% CI, –7.07 to 7.50; p=0.95; I2=98%) (Fig. 3). Upon conducting a sensitivity analysis by removing Desai et al.,25 Nijhawan et al.,22 and Xiang et al.24’s studies, the heterogeneity remained high (I2=93%) and the difference between the mean procedure times remained insignificant between the two positions (Supplementary Fig. 6).
Adverse events
Cardiopulmonary complications and PEP were reported in seven studies (n=2,155) and eight studies (n=2,133), respectively. There was no significant difference between the supine and PPs for either outcome: cardiopulmonary complications (OR, 1.08; 95% CI, 0.47–2.48; p=0.86, I2=91%) (Fig. 4) and PEP (OR, 1.12; 95% CI, 0.52–2.42; p=0.31; I2=15%) (Fig. 5). A sensitivity analysis excluding studies by Desai et al.,25 Trecero et al.,23 and Xiang et al.24 was performed for cardiopulmonary complications. Despite a slight reduction in heterogeneity (I2=86%), the results remained non-significant, as shown in Supplementary Figure 7.
Sensitivity analysis
We conducted a sensitivity analysis excluding all studies available only in abstract form. Notably, the exclusion of these studies did not result in any meaningful changes to our findings. The PP continued to demonstrate a statistically significant advantage in technical success over the SP. Similarly, there remained no significant difference in mean procedure time, the incidence of cardiopulmonary complications, or the rate of PEP between the two groups. These results confirm the robustness of our primary analysis and suggest that the inclusion of abstract-only studies did not materially influence the overall conclusions of the meta-analysis, as demonstrated in Supplementary Figures 8–11.
We conducted a sensitivity analysis excluding Osagiede et al.16 from the analyses of technical success and mean procedure time, as it contributes over 90% of the pooled patient population. The results remained consistent with the original findings; the PP continued to show a statistically significant advantage in technical success, and no significant difference was observed in mean procedure time between the two positions as observed in Supplemental Figures 12 and 13. These results suggest that our main conclusions are robust and not unduly driven by the disproportionate size of the Osagiede dataset.
We conducted a comprehensive systematic review and meta-analysis of 11 studies, constituting the largest sample size to date (n=24,285), to compare the technical success, mean procedure time, and number of adverse events between ERCP in PP and SP. Based on our analysis, the PP had a significantly higher technical success rate than the SP. The PP has traditionally been preferred for performing ERCPs because it allows easier intubation of the esophagus and optimal cannulation of the papilla, resulting in high-quality radiographic images and a lower aspiration risk.6 Additionally, it is the position in which endoscopists receive their training to perform ERCPs, thereby making it their preferred default.1,26 The widespread adoption of the PP is further supported by the relative lack of data on the feasibility and limitations of alternate positions, reinforcing its status as the preferred position.
Although the PP is deemed better from an endoscopist’s perspective, it is not ideal for all patients. SP is considered more comfortable for patients and anesthesiologists,10 and is favored in patients requiring general anesthesia with tracheal intubation as it offers enhanced airway control and facilitates easier saliva suction and rapid resuscitation maneuvers compared to the PP. It is also the position of choice in patients with morbid obesity, gross ascites, recent abdominal or neck surgery, abdominal pain, indwelling percutaneous gastrostomy or jejunostomy tubes, hilar biliary strictures, or previous Billroth II gastrectomies1,8,9 Additionally, as described by Tringali et al.,9 it allows for better evaluation of biliary and pancreatic anatomy by naturally positioning the liver and pancreas on the spine under the force of gravity, leading to accurate visualization of these structures. A previous meta-analysis of six studies reporting on 309 supine and 1415 prone ERCPs observed a significantly greater technical success rate in the PP than in the SP (95.6% vs. 89.1%).10 However, the study was limited by the absence of a direct comparison. The observations made by existing studies validate our results.21,25 Diehl21 prospectively assigned patients to one of the two positions and found a 96.5% clinical success rate in the PP compared to 88% in the SP (p<0.05). Another prospective randomized study by Terruzzi et al.8 yielded similar results, demonstrating an even lower technical success rate in the SP (70%). The cannulation rate was 70% in the SP compared to 100% in the PP, with a nearly significant p-value of 0.052. Notably, four of the five patients who initially failed to achieve biliary cannulation in the SP were successfully cannulated when repositioned in the PP. Notably, only one patient in the PP had a cardiopulmonary complication compared to seven patients in the SP, leading the researchers to conclude that the SP is technically more challenging for operators and may pose greater risk to patients.
More recently, a retrospective study by Osagiede et al.,16 performed using a large national database (21,090 patients) including the experiences of multiple endoscopists over a decade, showed significantly poor visualization and cannulization of the common bile duct (adjusted OR [aOR], 0.63; 95% CI, 0.44–0.91; p=0.011) and higher odds of an incomplete examination (aOR, 1.84; 95% CI, 1.46–2.30; p<0.001) in the SP than in the PP. Accordingly, Ferreira and Baron6 and Terruzzi et al.8 demonstrated a significant degree of procedural challenges in the SP (p<0.001) and a significantly lower median Freeman score in the PP (1 vs. 3, p=0.0047). These observations offer a possible explanation for the lower technical success rate in the SP, reaffirming our results and reinforcing the superiority of the PP.
Conversely, no significant difference was observed in the mean procedure time between the two positions. Our findings align with those of a previous study, which reported mean procedure times of 29.8 and 30 min in the PP and SP, respectively, without any statistically significant difference.10 Similarly, Ferreira and Baron,6 in their retrospective analysis of 649 ERCPs, observed a higher mean procedure time in the SP than in the PP (43 vs. 36 minutes, respectively), with no significant variation (p=0.054). Although Trecero et al.23 described a longer procedure time in the PP, their results yielded no statistical significance, similar to our results.
In contrast, Osagiede et al.16 observed a significant difference in the mean procedure time between the two groups, with a longer duration noted in the PP. However, this finding may be misrepresentative given the better technical success associated with the PP in the same study. The authors hypothesized that the increased procedure time was owing to the rotation and repositioning of the patient after intubation once the procedure was completed; this duration was not separately accounted for and was instead included in the overall mean procedure time.
Similar to the mean procedure time, the rates of adverse events, such as cardiopulmonary complications (OR, 1.08; 95% CI, 0.47–2.48; p=0.86) and PEP (OR, 1.12; 95% CI, 0.52–2.42; p=0.31), were comparable between the two groups, an observation contrasting the results of Terruzzi et al.8 (41% vs. 6%, p=0.039) and a recent RCT by Xiang et al.24 (OR, 0.17; 95% CI, 0.18–0.56; p<0.001), both reporting a significant rate of cardiopulmonary events in the SP compared to the PP. However, our findings are consistent with those of previous studies by Issa et al.17 and Ferreira and Baron.6 Notably, one of the studies that reported comparable complication rates between the two positions also observed significantly increased procedural difficulty in the SP.6 Similarly, a study that demonstrated significantly fewer cardiopulmonary complications and PEP in the SP did so with a lower technical success rate.10 These observations suggest a compromise between technical success and the risk of complications. Nonetheless, further studies are needed to investigate these outcomes and validate the results of our study.
Additionally, it should be acknowledged that deviation from the endoscopist's accustomed working position may negatively impact procedural performance and outcomes. Moreover, the endoscopist’s familiarity is a determinant of various adverse events in the SP and PP.17 Hence, the endoscopist should possess comparable experience in both positions to ensure an accurate assessment of procedural success. In their prospective analysis of 64 supine ERCPs and 25 prone ERCPs by novice advanced endoscopy trainees, Issa et al.17 suggested early simultaneous training for both the PP and SP, as the cannulation (98% vs. 69%, p=0.95) and PEP (8% vs. 7.8%, p=1) rates were comparable in both groups.
We acknowledge the limitations of this study. Nearly half of the included studies were available only in abstract form, which limits the ability to fully assess study quality, methodological rigor, and outcome completeness. To address this, we conducted a sensitivity analysis excluding the abstract-only studies, which corroborated the results of the primary analysis, confirming the robustness of our primary analysis. Notably, one large retrospective study by Osagiede et al.16 contributed over 90% of the total patient population, which may have disproportionately influenced the pooled estimates and affected the overall interpretation. To address this potential bias, we conducted a sensitivity analysis, which confirmed our primary findings, allowing us to report our conclusions with confidence. This concern was further compounded by the markedly higher number of ERCPs in PP than in SP across the included studies. However, it is essential to note that a sizeable multi-center study with a nearly equal distribution of prone and supine ERCPs (465 and 495, respectively) reported significantly higher cannulation of the desired duct in the PP than in the SP.25 Another limitation of this study is the lack of consistent data on operator experience, case complexity, and sedation technique used (for example, intravenous sedation vs general anesthesia). Operator experience and case complexity are well-established factors that influence technical success and complication rates in ERCP, while the sedation method may affect the risk of specific complications such as aspiration. As these variables were not adequately available in our data, their potential confounding effects could not be accounted for in the analysis. Future research should aim to include these factors to allow for more accurate risk stratification and assessment of procedural outcomes. Lastly, our meta-analysis included only one RCT, with a predominance of observational studies, which may impact the reliability of pooled effect estimates. Therefore, additional well-designed RCTs are needed to more definitely evaluate the comparative safety and efficacy of SP versus PP in ERCP and to validate our findings.
In conclusion, our meta-analysis affirmed the superiority of the PP in achieving successful ERCP, with no significant increase in procedure times or adverse events, including cardiopulmonary complications and PEP, compared with SP. However, given the comparable procedure times, incidence of adverse events, and increased comfort for both patients and anesthesiologists, the SP may be a suitable alternative for a select group of patients in whom the PP is not feasible such as those with morbid obesity, recent abdominal surgery, or specific anatomical challenges like those seen in post-Billroth II gastrectomy.8,9
Supplementary Table 1. Search strategy.
ce-2025-072-Supplementary-Table-1.pdf
Supplementary Table 2. Newcastle-Ottawa scale for cohort studies.
ce-2025-072-Supplementary-Table-2.pdf
Supplementary Table 3. Summary of findings using Grading of Recommendations, Assessment, Development, and Evaluation assessment of outcomes.
ce-2025-072-Supplementary-Table-3.pdf
Supplementary Fig. 1. Cochrane risk-of-bias assessment for randomized-controlled trials.
ce-2025-072-Supplementary-Fig-1.pdf
Supplementary Fig. 2. Funnel plot for cardiopulmonary complications.
ce-2025-072-Supplementary-Fig-2.pdf
Supplementary Fig. 3. Funnel plot for post-endoscopic retrograde cholangiopancreatography pancreatitis.
ce-2025-072-Supplementary-Fig-3.pdf
Supplementary Fig. 4. Funnel plot for technical success.
ce-2025-072-Supplementary-Fig-4.pdf
Supplementary Fig. 5. Funnel plot for mean procedure time.
ce-2025-072-Supplementary-Fig-5.pdf
Supplementary Fig. 6. Forest plot of mean procedure time after sensitivity analysis.
ce-2025-072-Supplementary-Fig-6.pdf
Supplementary Fig. 7. Forest plot of cardiopulmonary complications after sensitivity analysis.
ce-2025-072-Supplementary-Fig-7.pdf
Supplementary Fig. 8. Forest plot of technical success after sensitivity analysis (excluding abstract studies).
ce-2025-072-Supplementary-Fig-8.pdf
Supplementary Fig. 9. Forest plot of mean procedure time after sensitivity analysis (excluding abstract studies).
ce-2025-072-Supplementary-Fig-9.pdf
Supplementary Fig. 10. Forest plot of cardiopulmonary complications after sensitivity analysis (excluding abstract studies).
ce-2025-072-Supplementary-Fig-10.pdf
Supplementary Fig. 11. Forest plot of post-endoscopic retrograde cholangiopancreatography pancreatitis after sensitivity analysis (excluding abstract studies).
ce-2025-072-Supplementary-Fig-11.pdf
Supplementary Fig. 12. Forest plot of technical success after sensitivity analysis (excluding Osagiede et al.16).
ce-2025-072-Supplementary-Fig-12.pdf
Supplementary Fig. 13. Forest plot of mean procedure time after sensitivity analysis (excluding Osagiede et al.16).
ce-2025-072-Supplementary-Fig-13.pdf
Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2025.072.
Fig. 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart for study selection. A flowchart depicting the selection process of studies included in the systematic review.
ce-2025-072f1.jpg
Fig. 2.
Technical success. Forest plot comparing technical success in supine and prone positions across multiple studies. IV, inverse variance; CI, confidence interval.
ce-2025-072f2.jpg
Fig. 3.
Mean procedure times. Forest plot comparing mean procedure times in supine and prone positions across studies. SD, standard deviation; IV, intravenous; CI, confidence interval.
ce-2025-072f3.jpg
Fig. 4.
Cardiopulmonary complications. Forest plot comparing the incidence of cardiopulmonary complications in supine and prone positions. IV, intravenous; CI, confidence interval.
ce-2025-072f4.jpg
Fig. 5.
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Forest plot comparing the incidence of post-ERCP pancreatitis in supine and prone positions. IV, intravenous; CI, confidence interval.
ce-2025-072f5.jpg
ce-2025-072f6.jpg
Table 1.
Study characteristics
Study Year Country Type of study Study duration Sample size No. of supine ERCP No. of prone ERCP
Manomaipiboon et al.20 2000 Thailand Prospective cohort March 1995 to April 1999 180 130 123
Terruzzi et al.8 2005 Italy Prospective cohort NR 34 17 17
Diehl21 2006 USA Prospective cohort NR 784 41 779
Tringali et al.9 2008 Italy Prospective cohort December 2005 to May 2006 120 60 60
Ferreira and Baron6 2008 USA Retrospective cohort January 2006 to July 2007 649 143 506
Nijhawan et al.22 2010 India Prospective cohort NR 40 20 20
Trecero et al.23 2010 Philippines Prospective cohort August 2008 to October 2008 63 28 33
Osagiede et al.16 2021 USA Retrospective cohort January 2000 to December 2012 21,090 1,769 19,321
Xiang et al.24 2023 China Randomized-controlled trial NR 242 121 121
Issa et al.17 2023 USA Prospective cohort NR 89 64 25
Desai et al.25 2023 USA Retrospective cohort NR 960 495 465

ERCP, endoscopic retrograde cholangiopancreatography; NR, not reported.

Table 2.
Patient characteristics
Study Year No. of participants
 Male (fraction; n, %)
 Female (fraction; n, %)
 Mean age (yr, SD)
Supine Prone Supine Prone Supine Prone Supine Prone
Manomaipiboon et al.20 2000 90 90 NR NR NR NR NR NR
Terruzzi et al.8 2005 17 17 9/17 (52.9) 12/17 (70.6) 8/17 (47.1) 5/17 (29.4) 66.1 (21.2) 62.6 (12.0)
Diehl21 2006 41 779 NR NR NR NR NR NR
Tringali et al.9 2008 60 60 21/60 (35.0) 33/60 (55.0) 39/60 (65.0) 27/60 (45.0) 61.1 (16.9) 57.3 (14.7)
Ferreira and Baron6 2008 143 506 85/143 (59.4) 255/506 (50.4) 58/143 (40.6) 251/506 (49.6) 60 (24.4) 59 (17.2)
Nijhawan et al.22 2010 20 20 NR NR NR NR NR NR
Trecero et al.23 2010 28 33 NR NR NR NR NR NR
Osagiede et al.16 2021 1769 19321 809/1,769 (45.7) 10,173/19,321 (52.7) 960/1,769 (54.3) 9,148/19,321 (47.3) 58.0 (18.8) 56.9 (18.8)
Xiang et al.24 2023 121 121 63/121 (52.1) 65/121 (53.7) 58/121 (47.9) 56/121 (46.3) 61.2 (15.8) 58.4 (14.9)
Issa et al.17 2023 64 25 32/64 (50.0) 14/25 (56.0) NR NR 60.0 (17.5) 65.0 (18.0)
Desai et al.25 2023 495 465 235/495 (47.5) 259/465 (55.7) NR NR 65.4 (18.6) 62.9 (17.1)

SD, standard deviation; NR, not reported.

Table 3.
Outcomes
Study Year Success
 Mean procedure time (min, SD)
 Adverse events
Cardiopulmonary complications
 PEP
Supine Prone Supine Prone Supine Prone Supine Prone
Manomaipiboon et al.20 2000 121 113 NR NR NR NR 7 4
Terruzzi et al.8 2005 12 17 33.4 (16.5) 29.5 (8.1) 7 1 1 1
Diehl21 2006 36 752 NR NR NR NR NR NR
Tringali et al.9 2008 59 60 NR NR 14 15 1 1
Ferreira and Baron6 2008 129 468 43.0 (30.5) 36.0 (28.7) 60 356 2 16
Nijhawan et al.22 2010 18 18 13.0 (4) 15.0 (5) NR NR 2 2
Trecero et al.23 2010 26 33 38.17 46.48 13 18 0 2
Osagiede et al.16 2021 935 13702 29.7 (22.4) 39.8 (24.4) NR NR NR NR
Xiang et al.24 2023 NR NR 35.2 (7.2) 33.9 (6.7) 42 10 NR NR
Issa et al.17 2023 44 17 31.7 (14.8) 42.0 (23.2) 0 0 5 2
Desai et al.25 2023 471 459 34.1 (20.8) 23.4 (13.4) 241 301 14 0

SD, standard deviation; PEP, post-endoscopic retrograde cholangiopancreatography pancreatitis; NR, not reported.

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        Comparative efficacy and safety of supine versus prone positioning in endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis
        Clin Endosc. 2025;58(6):843-853.   Published online August 26, 2025
        DOI: https://doi.org/10.5946/ce.2025.072
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      Comparative efficacy and safety of supine versus prone positioning in endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis
      Image Image Image Image Image Image
      Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart for study selection. A flowchart depicting the selection process of studies included in the systematic review.
      Fig. 2. Technical success. Forest plot comparing technical success in supine and prone positions across multiple studies. IV, inverse variance; CI, confidence interval.
      Fig. 3. Mean procedure times. Forest plot comparing mean procedure times in supine and prone positions across studies. SD, standard deviation; IV, intravenous; CI, confidence interval.
      Fig. 4. Cardiopulmonary complications. Forest plot comparing the incidence of cardiopulmonary complications in supine and prone positions. IV, intravenous; CI, confidence interval.
      Fig. 5. Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Forest plot comparing the incidence of post-ERCP pancreatitis in supine and prone positions. IV, intravenous; CI, confidence interval.
      Graphical abstract

      Fig. 1.

      Fig. 2.

      Fig. 3.

      Fig. 4.

      Fig. 5.

      Graphical abstract

      Comparative efficacy and safety of supine versus prone positioning in endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis
      Study Year Country Type of study Study duration Sample size No. of supine ERCP No. of prone ERCP
      Manomaipiboon et al.20 2000 Thailand Prospective cohort March 1995 to April 1999 180 130 123
      Terruzzi et al.8 2005 Italy Prospective cohort NR 34 17 17
      Diehl21 2006 USA Prospective cohort NR 784 41 779
      Tringali et al.9 2008 Italy Prospective cohort December 2005 to May 2006 120 60 60
      Ferreira and Baron6 2008 USA Retrospective cohort January 2006 to July 2007 649 143 506
      Nijhawan et al.22 2010 India Prospective cohort NR 40 20 20
      Trecero et al.23 2010 Philippines Prospective cohort August 2008 to October 2008 63 28 33
      Osagiede et al.16 2021 USA Retrospective cohort January 2000 to December 2012 21,090 1,769 19,321
      Xiang et al.24 2023 China Randomized-controlled trial NR 242 121 121
      Issa et al.17 2023 USA Prospective cohort NR 89 64 25
      Desai et al.25 2023 USA Retrospective cohort NR 960 495 465
      Study Year No. of participants
      		 Male (fraction; n, %)
      		 Female (fraction; n, %)
      		 Mean age (yr, SD)
      Supine Prone Supine Prone Supine Prone Supine Prone
      Manomaipiboon et al.20 2000 90 90 NR NR NR NR NR NR
      Terruzzi et al.8 2005 17 17 9/17 (52.9) 12/17 (70.6) 8/17 (47.1) 5/17 (29.4) 66.1 (21.2) 62.6 (12.0)
      Diehl21 2006 41 779 NR NR NR NR NR NR
      Tringali et al.9 2008 60 60 21/60 (35.0) 33/60 (55.0) 39/60 (65.0) 27/60 (45.0) 61.1 (16.9) 57.3 (14.7)
      Ferreira and Baron6 2008 143 506 85/143 (59.4) 255/506 (50.4) 58/143 (40.6) 251/506 (49.6) 60 (24.4) 59 (17.2)
      Nijhawan et al.22 2010 20 20 NR NR NR NR NR NR
      Trecero et al.23 2010 28 33 NR NR NR NR NR NR
      Osagiede et al.16 2021 1769 19321 809/1,769 (45.7) 10,173/19,321 (52.7) 960/1,769 (54.3) 9,148/19,321 (47.3) 58.0 (18.8) 56.9 (18.8)
      Xiang et al.24 2023 121 121 63/121 (52.1) 65/121 (53.7) 58/121 (47.9) 56/121 (46.3) 61.2 (15.8) 58.4 (14.9)
      Issa et al.17 2023 64 25 32/64 (50.0) 14/25 (56.0) NR NR 60.0 (17.5) 65.0 (18.0)
      Desai et al.25 2023 495 465 235/495 (47.5) 259/465 (55.7) NR NR 65.4 (18.6) 62.9 (17.1)
      Study Year Success
      		 Mean procedure time (min, SD)
      		 Adverse events
      Cardiopulmonary complications
      		 PEP
      Supine Prone Supine Prone Supine Prone Supine Prone
      Manomaipiboon et al.20 2000 121 113 NR NR NR NR 7 4
      Terruzzi et al.8 2005 12 17 33.4 (16.5) 29.5 (8.1) 7 1 1 1
      Diehl21 2006 36 752 NR NR NR NR NR NR
      Tringali et al.9 2008 59 60 NR NR 14 15 1 1
      Ferreira and Baron6 2008 129 468 43.0 (30.5) 36.0 (28.7) 60 356 2 16
      Nijhawan et al.22 2010 18 18 13.0 (4) 15.0 (5) NR NR 2 2
      Trecero et al.23 2010 26 33 38.17 46.48 13 18 0 2
      Osagiede et al.16 2021 935 13702 29.7 (22.4) 39.8 (24.4) NR NR NR NR
      Xiang et al.24 2023 NR NR 35.2 (7.2) 33.9 (6.7) 42 10 NR NR
      Issa et al.17 2023 44 17 31.7 (14.8) 42.0 (23.2) 0 0 5 2
      Desai et al.25 2023 471 459 34.1 (20.8) 23.4 (13.4) 241 301 14 0
      Table 1. Study characteristics

      ERCP, endoscopic retrograde cholangiopancreatography; NR, not reported.

      Table 2. Patient characteristics

      SD, standard deviation; NR, not reported.

      Table 3. Outcomes

      SD, standard deviation; PEP, post-endoscopic retrograde cholangiopancreatography pancreatitis; NR, not reported.

      Table 1.

      Table 2.

      Table 3.

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