Forward Viewing Endoscopy at the Time of ERCP: A Blinded Tandem Prospective Trial

Key Takeaways for GI Nurses

• In this tandem trial, adding a forward-viewing endoscopic exam prior to ERCP identified additional findings in 42.3% of patients that were missed by the side-viewing duodenoscope alone, with 22.7% of patients having clinically significant findings that could change management.
• Because the standard side-viewing duodenoscope has a limited field of view by design, nurses should understand that this is an inherent limitation of the equipment—not an error in technique—and may warrant practice changes in pre-procedure planning and equipment setup.
• Patients with comorbid malignancy were statistically more likely to have findings missed on side-viewing exam alone, suggesting this subgroup may benefit most from a combined forward- and side-viewing approach.
• Nurses assisting in ERCP should be prepared for potential workflow changes, including scope exchanges, extended procedure times, and additional equipment reprocessing if forward-viewing exams become more routine practice.

Clinical Relevance

For endoscopy nurses, this study highlights an important gap in current ERCP practice that has direct implications for patient safety and procedural completeness. The duodenoscope's side-viewing optics are essential for cannulating the ampulla, but this design inherently limits visualization of the esophagus, stomach, and duodenal mucosa outside the periampullary region. Nurses who circulate or assist during ERCP should recognize that a "normal" ERCP does not necessarily mean the entire upper GI tract has been adequately surveyed—a nuance that may be important when documenting findings or fielding patient questions post-procedure.

From an operational standpoint, if institutions move toward incorporating a forward-viewing exam (either before or during ERCP), nursing teams should anticipate implications for scheduling, room turnover, and equipment logistics. This may mean stocking an additional forward-viewing endoscope in the ERCP suite, coordinating two scope setups, and adjusting time blocks to accommodate a tandem exam. Sterile processing and inventory management teams should also be looped in early, as this practice change would increase reprocessing volume and require careful tracking of two scopes per case rather than one.

This study also reinforces the value of thorough pre-procedure assessment and risk stratification. Nurses conducting pre-procedure interviews and chart reviews should pay particular attention to patients with known or suspected malignancy, as this population was shown to have a higher likelihood of missed findings on side-viewing exam alone. Flagging these patients for the endoscopy team may prompt consideration of a forward-viewing component, supporting a more individualized, risk-based approach to procedural planning rather than a one-size-fits-all ERCP protocol.

Bottom Line

This study suggests that relying solely on a side-viewing duodenoscope during ERCP may cause endoscopists to miss clinically significant findings in roughly one in five patients—particularly those with comorbid malignancy—reinforcing the importance of nurses supporting comprehensive pre-procedure risk assessment and staying informed about evolving practice standards that may incorporate forward-viewing exams into routine ERCP workflows.