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Background According to the British Society of Gastroenterology (BSG) guidelines on sedation in gastrointestinal endoscopy (2023), minimal to moderate sedation is typically sufficient for level 1/2 endoscopic retrograde cholangiopancreatography (ERCP). However, deep sedation is not routinely available in many centres, potentially affecting patient comfort and procedure completion. Repeat procedures increase patient risk and are not cost effective. This study investigated factors associated with incomplete ERCP procedures, with a particular focus on patient intolerance.Methods A retrospective review of all ERCP’s performed over 24 months at our tertiary centre was conducted. Data collected included demographics, indication, urgency, trainee involvement, ERCP grade, sedation used, comfort score, cannulation rate and completion of procedure (eg complete duct clearance). Achieving the primary therapeutic or diagnostic goal served as the primary outcome. Univariate and multivariable analyses were used to evaluate factors contributing to incomplete procedures.Results 1772 ERCPs were analysed (median age 67 years; range 13–97; 50.5% female) with top 3 indications being bile duct stones (n=808), mass/stricture (n=648) and bile leak (n=103). These comprised 80 grade 1, 867 grade 2, 706 grade 3 and 119 grade 4 procedures with trainee involvement in 1039 (58.6%). GA was used in 273/1772 (15.4%) procedures. Successful cannulation was achieved in 1624/1772 (91.6%) but 343/1772 (19.4%) were incomplete. Of these 280/343 (81.6%) could be attributed to lack of effective sedation (e.g. intolerance). Univariate analysis showed incomplete procedures were associated with increasing ERCP grade (p<0.0001), urgency (p=0.0003), increasing comfort score (p<0.0001), lack of cannulation (p<0.0001), higher opiate doses (p<0.0001) and higher midazolam doses (p<0.0001) but not trainee involvement, age, sex or anaesthesia. Multivariable analysis revealed incomplete procedures were independently associated with grade 3 (OR 2.4, 1.7-3.4, p=0.0001), grade 4 (OR 2.9, 1.6-5.4, p=0.0006), comfort score 1 (OR 1.7, 1.2-2.5, p=0.0045), comfort score 2 (OR 2.4, 1.5-3.9, p=0.0006), comfort score 3 (OR 11.8, 6.6-21.2, p=0.0001) and increasing opiate dose (OR 1.01, 1.00-1.01, p=0.004). Being 2 week wait status was beneficial (OR 0.17, 0.04-0.84, p=0.029).Conclusion Despite good cannulation rates, incomplete ERCP occurred in around 1 in 5 patients of which 4 in 5 of these could be attributed to lack of effective sedation. Incomplete procedures were associated with worse comfort scores, higher doses of sedation and increasingly complex procedures. These data concur with the BSG sedation guidelines and strongly support routine use of deep sedation/anaesthesia for ERCP.