1
|
Barakat MT, Liman A, Gugig R. Initial experience with duodenoscopes with single-use end caps in pediatric ERCP: infection prevention comes at a cost. Gastrointest Endosc 2024; 100:312-316. [PMID: 38462055 DOI: 10.1016/j.gie.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/11/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND AIMS Duodenoscopes with single-use end caps were introduced to minimize infection risk, but they are unstudied in pediatrics. METHODS We collected clinical data and endoscopists' evaluations of duodenoscopes with single-use end caps versus reusable duodenoscopes over 18 months. RESULTS A total of 106 ERCPs were performed for patients aged 1 to 18 (mean, 14.2) years. Forty-six involved single-use end caps, with 9 requiring crossover to reusable duodenoscopes. ERCPs involving single-use end caps resulted in more instances of mucosal trauma (10 vs 0; P < .05) and post-ERCP pancreatitis (4 vs 1; P < .05) and accounted for 8 of 9 ERCPs requiring advanced cannulation techniques. No post-ERCP infections occurred. Reported challenges included single-use end cap stiffness and difficulty with their alignment for cannulation. CONCLUSIONS We report difficulty with advancement, greater reliance on advanced cannulation techniques, and higher rates of post-ERCP pancreatitis when using duodenoscopes with single-use end caps in pediatric ERCP. This area warrants further study.
Collapse
Affiliation(s)
- Monique T Barakat
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford University School of Medicine, Palo Alto, California, USA; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andrew Liman
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford University School of Medicine, Palo Alto, California, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford University School of Medicine, Palo Alto, California, USA.
| |
Collapse
|
2
|
Zhang T, Shu Y, Weng H, Weng M, Zhou Y, Cai W, Wang X. A therapeutic ERCP in an only 5.9 kg infant with obstruction jaundice using JF-260V duodenoscope. BMC Pediatr 2024; 24:281. [PMID: 38678261 PMCID: PMC11055377 DOI: 10.1186/s12887-024-04765-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has found extensive use in pediatric patients; however, challenges persist in the application of therapeutic ERCP in infants. CASE PRESENTATION This case report details the presentation of a 5.9-kilogram infant with obstructive jaundice and suspected hemolytic anemia who underwent ERCP to alleviate biliary obstruction. The infant was admitted due to clay-colored stools, jaundice, and liver injury. Ultrasound and magnetic resonance cholangiopancreatography (MRCP) revealed dilation of the common bile duct (CBD) accompanied by the presence of stones. ERCP was conducted using a JF-260V duodenoscope under general anesthesia. Successful stone extraction and biliary drainage were achieved. CONCLUSIONS In centers with considerable expertise in ERCP and pediatric anesthesia, the use of a conventional adult duodenoscope for therapeutic ERCP in infants can be considered safe and feasible, provided careful and stringent patient selection criteria are applied. In the future, clear guidelines and standardized protocols for the indications and procedures of pediatric ERCP should be established.
Collapse
Affiliation(s)
- Tian Zhang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 KongJiang Street, Shanghai, 200092, China
| | - Yijun Shu
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Street, Shanghai, 200092, China
| | - Hao Weng
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Street, Shanghai, 200092, China
| | - Mingzhe Weng
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Street, Shanghai, 200092, China
| | - Ying Zhou
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 KongJiang Street, Shanghai, 200092, China
| | - Wei Cai
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 KongJiang Street, Shanghai, 200092, China
| | - Xuefeng Wang
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Street, Shanghai, 200092, China.
| |
Collapse
|
3
|
Kouchi K, Takenouchi A, Matsuoka A, Yabe K, Yoshizawa H, Nakata C, Fujishiro J, Sugiyama H. Case Series of Endoscopic Papillary Balloon Dilation for Children with Common Bile Duct Stones and a Review of the Literature. J Clin Med 2024; 13:2251. [PMID: 38673524 PMCID: PMC11050672 DOI: 10.3390/jcm13082251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Endoscopic sphincterotomy (EST) has been employed for the endoscopic treatment of common bile duct stones (CBDSs) and has been reported to have a high success rate for stone removal. However, EST is associated with a risk of bleeding, perforation, and sphincter of Oddi function disruption. To avoid these risks, endoscopic papillary balloon dilation (EPBD) is an option for CBDS. Sphincter of Oddi function preservation decreases long-term biliary infection and gallstone recurrence. EPBD may have advantages in children who require a long follow up. However, there have been few reports on pediatric cases, particularly in infants. Methods: From September 2017 to December 2023, we performed EPBD for four pediatric CBDSs. The patients were aged from 5 months to 8 years, including two infants aged 5 and 6 months. Furthermore, we reviewed the stone removal rate and complications of 545 ESTs performed at high-volume centers and 13 EPBD-reported cases in children with CBDSs. Results: CBDSs of all patients who underwent EPBD in our institution were successfully removed. No bleeding or perforation was noted; pancreatitis was observed in three patients. In an analysis of 545 ESTs in children, the stone removal rate was high, ranging from 83% to 100% (mean 96%). The incidence of pancreatitis was 0-9.6% (mean 4.4%), and the grade of pancreatitis was almost mild. The bleeding frequency was 1.3-5.4% (mean 2.7%). With regards to the grade of bleeding, seven cases were mild (64%) and four were moderate (36%). Compared with adults who underwent EST, the frequencies of pancreatitis and bleeding were almost equal in children; however, in children, once bleeding occurs, it has a higher risk of leading to blood transfusion. Stone removal via EPBD in children has a 100% success rate. Pancreatitis was responsible for all complications were related; its frequency was 46% (6/13 patients, including five mild cases and one moderate case), which is higher than that of EST and adult cases who underwent EPBD. In most children with pancreatitis, pancreatic enzyme levels returned to normal within 2-3 days following EPBD, and no severe cases caused by EPBD were reported. Conclusions: CBDS removal via EPBD in children has a high success rate with very low risk of bleeding and perforation. Although pancreatitis frequently occurs, most cases are mild. Sphincter of Oddi function preservation via EPBD is expected to prevent long-term stone recurrence and biliary tract infection, and EPBD is considered to be an effective method for CBDS removal in children.
Collapse
Affiliation(s)
- Katsunori Kouchi
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Ayako Takenouchi
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Aki Matsuoka
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Kiyoaki Yabe
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Hiroko Yoshizawa
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Chikako Nakata
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Tokyo University, Hongou 7-3-1, Bunkyou-ku, Tokyo 113-8655, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Tokyo Women's Medical University, 8-1 Shinjuku-ku, Tokyo 162-8666, Japan
| |
Collapse
|
4
|
Capparelli MA, Cotignola L, Domínguez MV, D'Alessandro PD, Ayarzabal VH, Barrenechea ME. Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis. J Pediatr Surg 2023; 58:2352-2355. [PMID: 37460346 DOI: 10.1016/j.jpedsurg.2023.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Gallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients. METHODS We conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors. RESULTS Eighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4-17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively. CONCLUSION Pediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD. LEVEL OF EVIDENCE Level II, retrospective study.
Collapse
Affiliation(s)
| | - Luciana Cotignola
- Division of General Surgery, J.P. Garrahan Hospital, Buenos Aires, Argentina
| | | | | | | | | |
Collapse
|
5
|
Hosseini A, Sohouli MH, Sharifi E, Sayyari A, Sridharan K, Tajalli S, Imanzadeh N, Fatahi S. Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis. BMC Pediatr 2023; 23:596. [PMID: 37996785 PMCID: PMC10668434 DOI: 10.1186/s12887-023-04392-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/27/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND To improve knowledge on endoscopic retrograde cholangiopancreatography (ERCP) in children, we aimed to study the proportion of indications, success rate and complication of ERCP. METHODS We performed a systematic search of all articles published up to December 2022 in the following databases: Cochrane Library, PubMed (MEDLINE) and Scopus. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by the I2 statistics and the Cochrane Q test. The included data were analyzed to identify the proportion of indications, success rate and complications of ERCP in children. RESULTS Based on data from 52 studies with a total of 5624 participants, the most common indications for ERCP in children were biliary [48% (95% CI: 0.40 - 0.57; I2 = 98.17%, P < 0.001)] and both biliary and pancreatic [41% (95% CI: 0.33 - 0.49; I2 = 98.27%, P < 0.001)]. The success rate of ERCP was 95% (95% CI: 0.94 - 0.96; I2 = 82.53%, P < 0.001) with the overall complication rate of 7% (95% CI: 0.05 - 0.09; I2 = 82.06%, P < 0.001). The pooled estimate for the incidence of post ERCP pancreatitis was 4% (95% CI: 0.03 - 0.06; I2 = 85.46%, P < 0.001) and the bleeding was 0% (95% CI: 0.0 - 0.0; I2 = 28.21%, P = 0.03). CONCLUSIONS ERCP appears to be performed safely in children with a similar success rate as in the adult population.
Collapse
Affiliation(s)
- Amirhossein Hosseini
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hassan Sohouli
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Sharifi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Aliakbar Sayyari
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Saleheh Tajalli
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Negar Imanzadeh
- School of pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somaye Fatahi
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
6
|
Niknam R, Mortazavi SMM, Jahromi MG, Davoodi M, Soheili M, Ataollahi M, Moshfeghinia R. Stone removal in a 5-year-old child with extrahepatic biliary obstruction using ERCP: A case report and a mini-review. Clin Case Rep 2023; 11:e7620. [PMID: 37520769 PMCID: PMC10374985 DOI: 10.1002/ccr3.7620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/03/2023] [Accepted: 06/13/2023] [Indexed: 08/01/2023] Open
Abstract
Key Clinical Message ERCP is a safe and effective method for managing biliary obstruction in children. A case report illustrates successful removal of a bile duct stone in a 5-year-old child using ERCP. Pediatric ERCP is a viable option for treating biliary diseases in well-equipped centers, alongside other approaches. Abstract We describe a 5-year-old child with extrahepatic biliary stone who successfully underwent endoscopic retrograde cholangiopancreatography for stone removal. He suffered from persistent colicky abdominal pain accompanied by fever that confirmed biliary stone. ERCP along with other methods, can be considered a safe procedure for managing BD in children.
Collapse
Affiliation(s)
- Ramin Niknam
- Gastroenterohepatology Research CenterShiraz University of Medical SciencesShirazIran
| | - Seyede Maryam Mahdavi Mortazavi
- Pediatric Gastroenterology Fellowship, Department of Pediatrics, School of MedicineNamazi teaching Hospital Shiraz University of Medical SciencesShirazIran
| | - Mehdi Ghaderian Jahromi
- Medical Imaging Research Center, Radiology DepartmentShiraz University of Medical SciencesShirazIran
| | - Marzieh Davoodi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Marzieh Soheili
- College of PharmacyWestern New England UniversitySpringfieldUSA
| | - Maryam Ataollahi
- Department of Pediatrics, School of Medicine Namazi teaching HospitalAbu Ali Sina for Medicine & Organ transplant Shiraz University of Medical SciencesShirazIran
| | - Reza Moshfeghinia
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- USERN officeShiraz University of Medical SciencesShirazIran
| |
Collapse
|
7
|
Grover AS, Gugig R, Barakat MT. Endoscopy and Pediatric Pancreatitis. Gastrointest Endosc Clin N Am 2023; 33:363-378. [PMID: 36948751 DOI: 10.1016/j.giec.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Children and adolescents are increasingly impacted by pancreatic disease. Interventional endoscopic procedures, including endoscopic retrograde cholangiopancreatography) and endoscopic ultrasonography, are integral to the diagnosis and management of many pancreatic diseases in the adult population. In the past decade, pediatric interventional endoscopic procedures have become more widely available, with invasive surgical procedures now being replaced by safer and less disruptive endoscopic interventions.
Collapse
Affiliation(s)
- Amit S Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA 94305, USA
| | - Monique T Barakat
- Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA 94305, USA; Division of Gastroenterology, Stanford University Medical Center, Stanford, CA 94305, USA.
| |
Collapse
|
8
|
Lorio E, Moreau C, Michalek JE, Patel S. Expanding the Use of Endoscopic Retrograde Cholangiopancreatography in Pediatrics: A National Database Analysis of Demographics and Complication Rates. Gastroenterology Res 2022; 15:314-324. [PMID: 36660468 PMCID: PMC9822666 DOI: 10.14740/gr1503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/21/2022] [Indexed: 12/23/2022] Open
Abstract
Background This study aimed to aid in risk assessment of pediatric endoscopic retrograde cholangiopancreatography (ERCP) candidates by utilizing a national pediatric database with a large sample to assess how patient characteristics may affect ERCP complication rates. Methods The Kids' Inpatient Database (KID) is a sample of pediatric discharges in states participating in the Healthcare Cost and Utilization Project (HCUP). This database provides demographic information, hospitalization duration, and outcome information for hospitalizations during which an ERCP occurred. International Classification of Diseases (ICD) codes were used to determine the hospitalization indication. ERCP complication rate was ascertained via ICD codes. All statistical analyses were performed using SAS 9.4. Results Complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. This analysis captured a large Hispanic population, specifically in the South and West regions. Gallbladder calculus and cholecystitis were more likely to occur in females. A higher percentage of patients in the age 10 - 17 group were female (72.2% vs. 52.7%, P < 0.01) and Hispanic (33.4% vs. 22.7%, P < 0.01) compared to the age 0 - 9 group. Age 0 - 5 and male gender were associated with lower routine home discharge rates and longer lengths of stay. Complications occurred at a higher rate in ages 0 - 5, though the difference was not statistically significant. Conclusions ERCP is a safe procedure for pediatric patients with low complication rates and rare mortality. We found statistically significant differences in the procedure indications between pediatric age groups, races, and genders. Age ≤ 5 years and male gender were associated with more complicated healthcare courses.
Collapse
Affiliation(s)
- Eric Lorio
- Department of Gastroenterology and Hepatology, Tulane University School of Medicine, New Orleans, LA, USA,Corresponding Author: Eric Lorio, Department of Gastroenterology and Hepatology, Tulane University School of Medicine, New Orleans, LA 70112, USA.
| | - Chris Moreau
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Texas Health San Antonio, TX, USA
| | - Joel Edmund Michalek
- Department of Population Health Sciences, University of Texas Health San Antonio, TX, USA
| | - Sandeep Patel
- Advanced Endoscopy Program, University of Texas Health San Antonio, TX, USA,Department of Gastrointestinal Endoscopy, University Hospital, San Antonio, TX, USA,CHRISTUS Health, San Antonio, TX, USA
| |
Collapse
|
9
|
Rashid R, Arfin MS, Karim ASMB, Alam MB, Mahmud S. Endoscopic Retrograde Cholangiopancreatography in Bangladeshi Children: Experiences and Challenges in a Developing Country. Pediatr Gastroenterol Hepatol Nutr 2022; 25:332-339. [PMID: 35903495 PMCID: PMC9284108 DOI: 10.5223/pghn.2022.25.4.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/18/2022] [Accepted: 04/14/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Although endoscopic retrograde cholangiopancreatography (ERCP) has been used for more than five decades, its applicability in Bangladeshi children has recently become more common. Therefore, this manuscript aims to describe our experience in performing ERCPs in Bangladeshi children with hepatopancreaticobiliary diseases, focusing on presenting diseases, as well as the diagnostic and therapeutic efficacy. METHODS Between 2018 and 2021, 20 children underwent 30 ERCP procedures at the Bangladesh Specialized Hospital, Dhaka. A single trained adult gastroenterologist performed all procedures using a therapeutic video duodenoscope. The indications for ERCP, diagnostic findings, therapeutic procedures, and complications were documented. RESULTS The median age of the study patients was 10 years (range, 1.7-15 years). Successful cannulation of the papilla was achieved in 28 procedures and failed in 2 cases. Repeated ERCP was required in seven patients. Nine patients had biliary indications and 11 had pancreatic indications. Choledocholithiasis was the most common indication for ERCP in patients with biliary disease, while chronic pancreatitis was common among patients with pancreatic indications. Pancreatic divisum was observed in only one patient. Pancreatic and biliary sphincterotomy was performed in 14 and 9 cases, respectively. A single pigtail or straight therapeutic stent was inserted in seven cases and removed in five cases. Stone extraction was performed in six procedures, and balloon dilatation was performed in five procedures. The post-procedural period for these patients was uneventful. CONCLUSION We found that ERCP is a practical and successful therapeutic intervention for treating hepatopancreaticobiliary disorders in children when performed by experienced endoscopists.
Collapse
Affiliation(s)
- Rafia Rashid
- Department of Pediatric Gastroenterology, Dr. MR Khan Shishu Hospital and Institute of Child Health, Dhaka, Bangladesh
| | - Md Samsul Arfin
- Department of Gastroenterology, Hepatology and Pancreatic Diseases (GHPD), Bangladesh Specialized Hospital, Dhaka, Bangladesh
| | - A S M Bazlul Karim
- Department of Pediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Salahuddin Mahmud
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Bangladesh Shishu Hospital and Institute, Dhaka, Bangladesh
| |
Collapse
|
10
|
Nathan JD, Ellery K, Balakrishnan K, Bhatt H, Ganoza A, Husain SZ, Kumar R, Morinville VD, Quiros JA, Schwarzenberg SJ, Sellers ZM, Uc A, Abu-El-Haija M. The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2022; 74:706-719. [PMID: 35258494 PMCID: PMC10286947 DOI: 10.1097/mpg.0000000000003439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children. METHODS The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP. RESULTS Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation. CONCLUSIONS The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.
Collapse
Affiliation(s)
- Jaimie D. Nathan
- Nationwide Children’s Hospital, Department of Abdominal Transplant and Hepatopancreatobiliary Surgery, The Ohio State University College of Medicine, Department of Surgery, Columbus, Ohio, United States
| | - Kate Ellery
- University of Pittsburgh Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh, Pennsylvania, United States
| | - Keshawadhana Balakrishnan
- Texas Children’s Hospital, Section of Pediatric Gastroenterology, Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States
| | - Heli Bhatt
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Armando Ganoza
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, Pittsburgh, Pennsylvania, United States
| | - Sohail Z. Husain
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Rakesh Kumar
- Promedica Russell J. Ebeid Children’s Hospital, Toledo, Ohio, United States
| | - Veronique D. Morinville
- McGill University Health Center, Montreal Children’s Hospital, Division of Pediatric Gastroenterology and Nutrition, Montreal, Quebec, Canada
| | - J. Antonio Quiros
- Icahn School of Medicine, Mount Sinai Kravis Children’s Hospital, New York, New York, United States
| | - Sarah J. Schwarzenberg
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Zachary M. Sellers
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Aliye Uc
- University of Iowa, Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, Iowa, United States
| | - Maisam Abu-El-Haija
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, United States
| |
Collapse
|
11
|
Dişçi E, Peksöz R, Yıldız M, Yıldırgan Mİ, Albayrak Y, Fakirullahoğlu M, Fırıncı B, Atamanalp SS. Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients. J Laparoendosc Adv Surg Tech A 2022; 32:320-324. [PMID: 35041496 DOI: 10.1089/lap.2021.0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used in the diagnosis and treatment of pancreaticobiliary system. ERCP is used less frequently in children than in adults due to the rarity of pancreaticobiliary diseases and technical difficulties. However, ERCP is a safe, effective diagnosis and treatment tool for children. Methods: All patients within the age range of 1-19 years, who underwent ERCP between 2010 and 2021 at our endoscopy unit, were retrospectively examined. Patient demographics, use of imaging methods, indications, type of sedation, interventions, success of ERCP, findings, and complications were evaluated. Results: Overall, 105 ERCPs were performed in 66 children (29 male and 37 female). The indications were choledocholithiasis, cyst hydatic, choledochal cyst, biliary atresia or anomaly, liver transplantation-related disorders, and pancreatic disorders, respectively. ERCP was finished as diagnostic ERCP in 20% and as therapeutic in 80%. Therapeutic procedures were sphincterotomy, stent placement or removal, stone or debris extraction, and balloon sweep or dilatation, respectively. The success rate in the procedures was 75.23%. The overall complication rate was 15.23%. Postprocedure pancreatitis occurred in 11.42%, hemorrhage occurred in 2.85%, and aggravation of cholangitis in 0.95%. All complications were managed conservatively. Conclusion: ERCP in pediatric patients is a safe procedure that can be performed by adult endoscopists with high success rates. Since our region is an endemic region for hydatid cyst disease, the most common ERCP indication after choledocholithiasis is procedures related to liver hydatid cyst disease. The most common complication was pancreatitis, and complications were treated medically.
Collapse
Affiliation(s)
- Esra Dişçi
- Department of General Surgery, Atatürk University Research Hospital, Erzurum, Turkey
| | - Rıfat Peksöz
- Department of General Surgery, Atatürk University Research Hospital, Erzurum, Turkey
| | - Metin Yıldız
- Department of General Surgery, Atatürk University Research Hospital, Erzurum, Turkey
| | | | - Yavuz Albayrak
- Department of General Surgery, Atatürk University Research Hospital, Erzurum, Turkey
| | | | - Binali Fırıncı
- Department of Pediatric Surgery, Atatürk University Research Hospital, Erzurum, Turkey
| | | |
Collapse
|
12
|
Sun R, Xu X, Zheng Q, Zhan J. Therapeutic Endoscopic Retrograde Cholangiopancreatography for Pediatric Hepato-Pancreato-Biliary Diseases: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:915085. [PMID: 35844750 PMCID: PMC9280719 DOI: 10.3389/fped.2022.915085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hepato-pancreato-biliary (HPB) disease has different causes and types between children and adults, which has been increasingly diagnosed in the pediatric group. Endoscopic retrograde cholangiopancreatography (ERCP) has been gradually considered as a therapeutic method in adults, while in pediatric patients, there are not many reports of its usage. This systematic review and meta-analysis aims to assess the use condition of therapeutic ERCP in the management of pediatric HPB diseases. METHODS This systematic literature search was conducted in the PubMed, Embase, Web of Science, and Cochrane library databases to identify all relevant articles published from inception to February 2022 that evaluated therapeutic ERCP in pediatric patients with HPB diseases. The researchers included studies in which patients were less than 18 years old and underwent therapeutic ERCP procedures. A random-effects model was used to analyze the usage rate of therapeutic ERCP procedures, procedural success rates, adverse event rates, and the rate of different therapeutic procedures. Subgroup analysis, sensitivity analysis, and meta-regression were conducted to analyze the source of heterogeneity. RESULTS A total of 33 articles were included. After homogenization, the overall use of therapeutic interventions accounts for 77% [95% confidence interval (CI) 74-81%] of all ERCP procedures. After excluding outlier studies, the estimation success rate of the therapeutic procedure is 74% (95% CI 69-79%), and adverse event rate is 8% (95% CI 6-10%). In our study, stent placement is the most common procedure, which makes up 75% (95% CI 65-86%) of all therapeutic procedures. In addition, the usage proportion of sphincterotomy (ST), stone extraction/removal, bougienage/balloon dilation is, respectively, 46% (95% CI 39-53%), 34% (95% CI 31-38%), and 26% (95% CI 22-29%). CONCLUSION The ERCP procedure is gradually considered a therapeutic technique in pediatric patients, the proportion of therapeutic ERCP is 77% of total usage, which is increasing every year. Meanwhile, its success rate is relatively high. It reflects that this operation modality is promising in the treatment of HPB disorders and is gradually expanded as more branch technologies are being used. A variety of operations can be achieved through ERCP procedures, and more functions should be developed in the future. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022302911].
Collapse
Affiliation(s)
- Rongjuan Sun
- Graduate School, Tianjin Medical University, Tianjin, China.,Department of General Surgery, Tianjin Children's Hospital, Tianjin, China
| | - Xiaodan Xu
- Graduate School, Tianjin Medical University, Tianjin, China.,Department of General Surgery, Tianjin Children's Hospital, Tianjin, China
| | - Qipeng Zheng
- Graduate School, Tianjin Medical University, Tianjin, China.,Department of General Surgery, Tianjin Children's Hospital, Tianjin, China
| | - Jianghua Zhan
- Department of General Surgery, Tianjin Children's Hospital, Tianjin, China
| |
Collapse
|
13
|
Weng M, Wang L, Weng H, Gu J, Wang X. Utility of endoscopic retrograde cholangiopancreatography in infant patients with conservational endoscopy. Transl Pediatr 2021; 10:2506-2513. [PMID: 34765474 PMCID: PMC8578769 DOI: 10.21037/tp-21-406] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/14/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The indications for endoscopic retrograde cholangiopancreatography (ERCP) in infant patients (age <1 year) differ from those in adults. A paucity of data and concerns about the potential lower effectiveness and more adverse effects limit its utility, even in tertiary care centres. In this study, we retrospectively analysed the indications, success rates, and adverse effects of ERCP in these groups. METHODS From June 2014 to March 2018, 17 ERCPs were performed in 15 children [median age: 10.4 months (6-12 months); median weight: 6.6 kg (3.3-10.7 kg)]. A conventional duodenoscope was utilized in all procedures. All patients were followed up as inpatients. RESULTS Fifteen therapeutic and two diagnostic procedures were managed by licensed paediatric endoscopist. Successful cannulation was obtained in all patients (100%). A high proportion (47.1%) of pancreaticobiliary maljunction (PBM) and therapeutic procedures (88.2%) were identified. Two cases of mild pancreatitis were recorded, accounting for 12.5% of the post-ERCP pancreatitis (PEP) rate. By multivariable analysis, recurrent acute pancreatitis and pancreatic duct (PD) cannulation/injection were identified as PEP-related risk factors. All complications were managed conservatively. CONCLUSIONS ERCP in infant patients (0.5< age <1 year) could be safely completed by conservational endoscopy. A high proportion of PBM and therapeutic procedures were identified in our study cohort. The overall adverse-event rate was acceptable, and no serious complication occurred. The PEP-related independent risk factors included recurrent acute pancreatitis and PD cannulation/injection.
Collapse
Affiliation(s)
- Mingzhe Weng
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lubing Wang
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Chongming Branch, Shanghai, China
| | - Hao Weng
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Gu
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuefeng Wang
- Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
14
|
Abstract
PURPOSE The prevalence of gallstones in children has increased over the last years. Choledocholithiasis (CD) is present in up to 30% of the cases. There is a scarcity of studies on the management of choledocholithiasis in children. The aim of this study was to develop a score that would allow predicting accurately the risk of CD in children with gallstones and reduce the number of non-therapeutic ERCP. MATERIALS AND METHODS We conducted a retrospective study in children with gallstones and suspected CD seen between January 2010 and December 2019. The main outcome was the presence of CD confirmed by at least one of the following diagnostic tests: magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and/or intraoperative cholangiography (IOC). We developed a risk score based on the presence or absence of the following risk factors: acute biliary pancreatitis, ascending cholangitis, elevated liver function tests (AST, ALT, total bilirubin [TB, ≥ 2 mg/dl], conjugated bilirubin, gamma-glutamyl transpeptidase, and alkaline phosphatase), CD on ultrasound (US; this was considered predictive but not confirmatory of CD), and dilation of the common bile duct (> 6 mm) by US. The score was divided into three different categories: low risk (no risk factors), intermediate risk (one risk factor present), high risk (≥ 2 risk factors present or ascending cholangitis). Given the main goal of reducing the number of diagnostic ERCPs, a very-high-risk subgroup (3 risk factors present or ascending cholangitis) was identified. RESULTS We reviewed 133 patients with gallstones and suspected CD. In 56 (42.1%) patients, the presence of CD was confirmed by one or more of the definitive diagnostic tests (MRCP, ERCP, and IOC). The following variables were found to be the strongest predictors of CD: ascending cholangitis, TB ≥ 2 mg/dl, common bile duct > 6 mm, and the presence of CD by US. The positive predictive value for CD was 7.5% in the low-risk group (OR 0.06, P = < 0.001); 22.9% in the intermediate-risk group (OR 0.31, P = 0.007); 77.6% in the high-risk group (OR 20.14, P = < 0.001); and 95.7% in very-high-risk subgroup (OR 49.18, P = < 0.001). CONCLUSION The risk score proposed in this study predicts accurately the presence of CD in children with gallstones. It can serve as a helpful tool to triage the need for costly and complex studies in the workup of CD, particularly in centers with limited resources. Finally, due to its high specificity and positive predictive value (PPV), the use of the very-high-risk criteria would allow for an important decrease in the number of non-therapeutic ERCP.
Collapse
|
15
|
Barakat MT, Cholankeril G, Gugig R, Berquist WE. Nationwide Evolution of Pediatric Endoscopic Retrograde Cholangiopancreatography Indications, Utilization, and Readmissions over Time. J Pediatr 2021; 232:159-165.e1. [PMID: 33197494 DOI: 10.1016/j.jpeds.2020.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/19/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To analyze outcome and utilization trends over time of pediatric endoscopic retrograde cholangiopancreatography (ERCP) in an all-capture US population-level study. STUDY DESIGN Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric (age <20 years) hospitalizations during which ERCP was performed and assessed ERCP-associated readmissions. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify hospitalization diagnoses, comorbidities, and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P < .05) of 30-day readmission. RESULTS A total of 11 060 hospitalized pediatric patients underwent ERCP between 2005 and 2014. Most were female (n = 8859; 81%), aged 14-20 years (n = 9342; 84%), and white (n = 4230; 45%). Most (85%) of ERCPs were therapeutic, and leading indications were biliary (n = 5350; 48%) and pancreatitis (n = 3218; 29%). Thirteen pecent of patients were readmitted post-ERCP. Odds for 30-day readmission were highest for patients with a history of liver transplantation, age 0-4 years, male sex, and obesity (P < .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than those in rural hospitals for prolonged length of stay associated with ERCP. CONCLUSIONS These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights into trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics, and patient comorbidities associated with pediatric post-ERCP outcomes, including readmission and length of stay.
Collapse
Affiliation(s)
- Monique T Barakat
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucille Packard Children's Hospital at Stanford University Medical Centerr, Stanford, CA; Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucille Packard Children's Hospital at Stanford University Medical Centerr, Stanford, CA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucille Packard Children's Hospital at Stanford University Medical Centerr, Stanford, CA.
| |
Collapse
|
16
|
Barakat MT, Gugig R, Imperial J, Berquist WE. Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Performed for Children and Adolescents is Significantly Higher With Low-volume Endoscopists. J Pediatr Gastroenterol Nutr 2021; 72:244-249. [PMID: 32833892 DOI: 10.1097/mpg.0000000000002914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist, and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults; however, the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP. METHODS We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002 to 2017 using our institution's paper and electronic medical record system along with a prospectively maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High-volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume >100 and low-volume endoscopists (LVE) as <100 (pediatric + adult) ERCPs/year. RESULTS Three hundred eighty-five ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas), and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times (FTs) varied between procedures and providers. Median FT was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P < 0.001). In addition to endoscopist volume, procedure-specific predictors of increased FT included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age <4 years or >16 years at the time of ERCP (P < 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with FT. CONCLUSIONS Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors, such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.
Collapse
Affiliation(s)
- Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - Joanne Imperial
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| |
Collapse
|
17
|
Abstract
Sickle hepatopathy is an umbrella term describing various pattern of liver injury seen in patients with sickle cell disease. The disease is not uncommon in India; in terms of prevalence, India is second only to Sub-Saharan Africa where sickle cell disease is most prevalent. Hepatic involvement in sickle cell disease is not uncommon. Liver disease may result from viral hepatitis and iron overload due to multiple transfusions of blood products or due to disease activity causing varying changes in vasculature. The clinical spectrum of disease ranges from ischemic injury due to sickling of red blood cells in hepatic sinusoids, pigment gall stones, and acute/chronic sequestration syndromes. The sequestration syndromes are usually episodic and self-limiting requiring conservative management such as antibiotics and intravenous fluids or packed red cell transfusions. However, rarely these episodes may present with coagulopathy and encephalopathy like acute liver failure, which are life-threatening, requiring exchange transfusions or even liver transplantation. However, evidence for their benefits, optimal indications, and threshold to start exchange transfusion is limited. Similarly, there is paucity of the literature regarding the end point of exchange transfusion in this scenario. Liver transplantation may also be beneficial in end-stage liver disease. Hydroxyurea, the antitumor agent, which is popularly used to prevent life-threatening complications such as acute chest syndrome or stroke in these patients, has been used only sparingly in hepatic sequestrations. The purpose of this review is to provide insights into epidemiology of sickle cell disease in India and pathogenesis and classification of hepatobiliary involvement in sickle cell disease. Finally, various management options including exchange transfusion, liver transplantation, and hydroxyurea in hepatic sequestration syndromes will be discussed in brief.
Collapse
Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACLF, Acute on chronic liver failure
- ALF, Acute liver failure
- ALT, Alanine transaminase
- AST, Aspartate transaminase
- FFP, Fresh frozen plasma
- GIT, Gastrointestinal tract
- HAV, Hepatitis A virus
- HBV, Hepatitis B virus
- HCV, Hepatitis C virus
- HEV, Hepatitis E virus
- HIC, Hepatic iron content
- HbS, Sickle hemoglobin
- HbSS, Sickle cell disease homozygous
- INR, International normalized ratio
- PT, Prothrombin time
- RUQ, Right upper quadrant
- SC, Scheduled caste
- SCD, Sickle cell disease
- SCIC, Sickle cell intrahepatic cholestasis
- ST, Scheduled tribe
- TJLB, Transjugular liver biopsy
- UDCA, Ursodeoxycholic acid
- cholelithiasis
- intrahepatic cholestasis
- sickle cell hepatopathy
- sickle cholangiopathy
- sickle hepatic crisis
Collapse
Affiliation(s)
| | - Anil C. Anand
- Address for correspondence. Anil C Anand, Professor and Head, Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubneshwar, India.
| |
Collapse
|
18
|
Barakat MT, Josephs S, Gugig R. Return to Native Drainage: Duodenal Biliary Fistula Formation Following Pediatric Hepatobiliary Surgery with Roux-en-Y Reconstruction. Dig Dis Sci 2021; 66:46-51. [PMID: 32533541 DOI: 10.1007/s10620-020-06372-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA. .,Division of Pediatric Gastroenterology and Hepatology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA, 94305, USA.
| | - Shellie Josephs
- Pediatric Interventional Radiology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA, 94305, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology and Hepatology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA, 94305, USA
| |
Collapse
|
19
|
Abstract
Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.
Collapse
|
20
|
Abstract
BACKGROUND AND AIMS Endoscopic procedures are important for diagnosis and management of many gastrointestinal, liver, and biliary conditions in children. Therapeutic endoscopy procedures, including endoscopic retrograde cholangiopancreatography (ERCP), are performed less frequently in children relative to adults. A formal study to evaluate institutional volumes and practice patterns for advanced therapeutic pediatric endoscopy procedures has, however, not been previously undertaken. METHODS A self-administered 16-question (5-minute) online survey assessing practice patterns for performance of pediatric endoscopy procedures was distributed to all registered North American Society for Pediatric Gastroenterology, Hepatology and Nutrition programs. Results were analyzed using descriptive statistics and thematic analysis of free-text comments. RESULTS Respondents from 82.9% of North American Society for Pediatric Gastroenterology, Hepatology and Nutrition centers completed this survey. Responses revealed that esophagogastroduodenoscopy/colonoscopy are performed at the vast majority of centers (>90%), with most performing >50/year. Therapeutic endoscopy procedures are performed less frequently in the pediatric population, with 18.97% reporting that ERCP is not performed at their institution. Where ERCP is performed, 91.38% reported <25/year. Endoscopic ultrasound is not performed at more than half (53.33%) of institutions. Approximately 71.67% of respondents do not believe their institution's current arrangement for performing pediatric therapeutic endoscopy procedures is adequate. CONCLUSIONS Although the range of endoscopic procedures performed in children parallels that performed in adults, there are notable differences in pediatric and adult gastroenterologists' endoscopy training and procedure volumes. Our results and respondent comments suggest that pediatric patients would benefit from a partnership between pediatric and adult gastroenterologists, with adult gastroenterologists performing more complex therapeutic endoscopic procedures.
Collapse
|
21
|
Asenov Y, Akın M, Cantez S, Gün Soysal F, Tekant Y. Endoscopic retrograde cholangiopancreatography in children: Retrospective series with a long-term follow-up and literature review. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 30:192-197. [PMID: 30459128 DOI: 10.5152/tjg.2018.18165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/AIMS To investigate the safety and long-term results of endoscopic retrograde cholangiopancreatography (ERCP) in children with a literature review. MATERIALS AND METHODS All patients within the age range of 6-17 years who underwent ERCP between 1994 and 2014 at our institution were retrospectively evaluated. RESULT Twenty-four patients with a median age of 15 years underwent ERCP. Cannulation of the papilla was achieved in all patients (100%) without the use of needle-knife papillotomy. Before 1999, ERCP was used as a diagnostic method only in 7 patients (29%). In 17 (71%) patients, the procedure was used for therapeutic purposes. The indications were choledocholithiasis (10 cases, 42%), postoperative complications (5 patients, 21%), and recurrent pancreatitis (2 cases, 8%). In 2 patients (8%), the therapeutic effect was not achieved, thus requiring subsequent operations. There were no major complications. Mild pancreatitis occurred in only 1 patient (4%). Long-term follow-up information was obtained in 16 (67%) patients (median, 18 years; range, 3.5-22.5 years), and no long-term complications were detected. CONCLUSION Endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis and treatment of pancreatobiliary disorders in the pediatric population. Large-scale studies are required to create evidence-based guidelines specific to children.
Collapse
Affiliation(s)
- Yavor Asenov
- Clinical Center of Gastroenterology, Medical University of Sofia, University Hospital "Tsaritsa Yoanna - ISUL", Sofia, Bulgaria
| | - Melih Akın
- Department of Pediatric Surgery, Health Sciences University Şişli Hamidiye Etfal Hospital, İstanbul, Turke
| | - Serdar Cantez
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, İstanbul University School of Medicine, İstanbul, Turkey
| | - Feryal Gün Soysal
- Department of Pediatric Surgery, İstanbul University School of Medicine, İstanbul, Turkey
| | - Yaman Tekant
- Hepatopancreatobiliary Surgery Unit, Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| |
Collapse
|
22
|
Acute pancreatitis in children. ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000535045.57816.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
23
|
Mark JA, Mack CL, Marwan AI, Kramer RE. Use of Fully Covered Self-expanding Metal Biliary Stents in Pediatrics: A Case Series. J Pediatr Gastroenterol Nutr 2018; 66:e71-e75. [PMID: 28837510 DOI: 10.1097/mpg.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography is used to manage biliary pathology in pediatric patients. Plastic biliary stents have been used in this population for obstructive lesions and bile leaks; however, they are sometimes not effective due to migration, occlusion, or ineffective sealing. Fully covered self-expanding metal stents (FCSEMS) have larger diameters making them more suitable for some situations. Their use in pediatrics has, however, not been defined. The aim of the present study is to describe our experience with FCSEMS at our institution. METHODS We present a series of all patients who underwent FCSEMS placement at Children's Hospital Colorado including 3 adolescents and 1 young adult with complex medical needs. RESULTS Patient age range was 12 to 24 years and the weight ranged between 36 and 75 kg. All patients underwent previous endoscopic retrograde cholangiopancreatography and 1 or more rounds of plastic stenting without adequate clinical response before consideration of FCSEMS placement. Indications included recalcitrant biliary anastomotic stricture after liver transplant, persistent bile leak after needle perforation, recurrent obstructive choledocholithiasis after cholecystectomy, and malignant biliary stricture. Sizes of FCSEMS depended on patient bile duct size and biliary pathology. Dwell time was 6 to 8 weeks. Three patients had resolution of biliary pathology after FCSEMS therapy. One patient had distal migration of FCSEMS necessitating repeat stenting. There were no adverse events from FCSEMS placement or removal. CONCLUSIONS FCSEMS therapy should be considered in appropriate pediatric patients when plastic biliary stents are not effective. Further studies are needed to evaluate the safety and efficacy of FCSEMS in the pediatric age group.
Collapse
Affiliation(s)
- Jacob A Mark
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| | - Cara L Mack
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| | - Ahmed I Marwan
- Division of Pediatric Surgery, Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO
| | - Robert E Kramer
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| |
Collapse
|
24
|
Nabi Z, Reddy DN. Advanced Therapeutic Gastrointestinal Endoscopy in Children - Today and Tomorrow. Clin Endosc 2018; 51:142-149. [PMID: 29228523 PMCID: PMC5903083 DOI: 10.5946/ce.2017.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/02/2017] [Accepted: 09/09/2017] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal (GI) endoscopy plays an indispensable role in the diagnosis and management of various pediatric GI disorders. While the pace of development of pediatric GI endoscopy has increased over the years, it remains sluggish compared to the advancements in GI endoscopic interventions available in adults. The predominant reasons that explain this observation include lack of formal training courses in advanced pediatric GI interventions, economic constraints in establishing a pediatric endoscopy unit, and unavailability of pediatric-specific devices and accessories. However, the situation is changing and more pediatric GI specialists are now performing complex GI procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography for various pancreatico-biliary diseases and more recently, per-oral endoscopic myotomy for achalasia cardia. Endoscopic procedures are associated with reduced morbidity and mortality compared to open surgery for GI disorders. Notable examples include chronic pancreatitis, pancreatic fluid collections, various biliary diseases, and achalasia cardia for which previously open surgery was the treatment modality of choice. A solid body of evidence supports the safety and efficacy of endoscopic management in adults. However, additions continue to be made to literature describing the pediatric population. An important consideration in children includes size of children, which in turn determines the selection of endoscopes and type of sedation that can be used for the procedure.
Collapse
Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Duvvur Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| |
Collapse
|
25
|
Yu PT, Fenton SJ, Delaplain PT, Vrecenak J, Adzick NS, Nance ML, Guner YS. Management of choledocholithiasis in an infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
26
|
Özcan N, Kahrıman G, Görkem SB, Arslan D. Percutaneous management of bile duct stones in children: results of 12 cases. Diagn Interv Radiol 2017; 23:133-136. [PMID: 28082252 DOI: 10.5152/dir.2016.16178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE We aimed to evaluate the effectiveness of percutaneous transhepatic removal of bile duct stones in children. METHODS The study included 12 pediatric patients (4 males, 8 females; age range, 1-16 years; mean age, 6.6 years) who underwent percutaneous transhepatic removal of bile duct stones between September 2007 and December 2015. Demographic data, patient symptoms, indications for interventions, technical and clinical outcomes of the procedure, and complications were retrospectively evaluated. RESULTS Of 12 children, five children with cholelithiasis underwent cholecystectomy subsequently. The overall technical and clinical success rate was 100%. One patient had cholangitis as a complication during the follow-up and was treated medically. CONCLUSION Percutaneous transhepatic removal of bile duct stones is a safe and effective method for the treatment of children with biliary stone disease. It is a feasible alternative when the endoscopic procedure is unavailable or fails.
Collapse
Affiliation(s)
- Nevzat Özcan
- Department of Radiology, Erciyes University School of Medicine, Gevher Nesibe Hospital, Kayseri, Turkey.
| | | | | | | |
Collapse
|
27
|
Shah R, Taborda C, Chawla S. Acute and chronic hepatobiliary manifestations of sickle cell disease: A review. World J Gastrointest Pathophysiol 2017; 8:108-116. [PMID: 28868180 PMCID: PMC5561431 DOI: 10.4291/wjgp.v8.i3.108] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/02/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023] Open
Abstract
Sickle cell disease (SCD) is a common hemoglobinopathy which can affect multiple organ systems in the body. Within the digestive tract, the hepatobiliary system is most commonly affected in SCD. The manifestations range from benign hyperbilirubinemia to overt liver failure, with the spectrum of acute clinical presentations often referred to as “sickle cell hepatopathy”. This is an umbrella term referring to liver dysfunction and hyperbilirubinemia due to intrahepatic sickling process during SCD crisis leading to ischemia, sequestration and cholestasis. In this review, we detail the pathophysiology, clinical presentation and biochemical features of various acute and chronic hepatobiliary manifestations of SCD and present and evaluate existing evidence with regards to management of this disease process. We also discuss recent advances and controversies such as the role of liver transplantation in sickle cell hepatopathy and highlight important questions in this field which would require further research. Our aim with this review is to help increase the understanding, aid in early diagnosis and improve management of this important disease process.
Collapse
|
28
|
Al Talhi Y, Shirah BH, Altowairqi M, Yousef Y. Laparoscopic cholecystectomy for cholelithiasis in children with sickle cell disease. Clin J Gastroenterol 2017; 10:320-326. [PMID: 28555355 DOI: 10.1007/s12328-017-0750-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/14/2017] [Indexed: 12/13/2022]
Abstract
Patients with sickle cell disease (SCD) suffer from an increased incidence of gallstone formation due to hemolysis of sickled red blood cells; this leads to an increased level of bilirubin in secreted bile that becomes a nidus for pigment stone formation. Laparoscopic cholecystectomy (LC) is considered a standard operative procedure for gallstone disease mainly due to lower postoperative wound complaints, faster recovery, better postoperative cosmetic results, shorter hospital stay, and earlier return to work. Although numerous studies have been published addressing both the advantages and complications of LC in acute calcular cholecystitis, there is still limited evidence concerning the safety and efficacy of LC for the management of cholelithiasis in pediatric patients with SCD, and controversies remain unresolved. In this review, we aim to comprehensively study the available literature and propose evidence-based practice recommendations for the optimal management of gallstones in pediatric SCD patients. The current practice differs greatly depending on the prevalence of SCD in a particular geographic area. We acknowledge the limited number of patients reported, the lack of randomized control trials addressing the practice of specific recommendations, and the need for further evidence-based studies.
Collapse
Affiliation(s)
- Yousef Al Talhi
- King Abdullah International Medical Research Centre, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 65362, Jeddah, 21556, Saudi Arabia
| | - Bader Hamza Shirah
- King Abdullah International Medical Research Centre, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 65362, Jeddah, 21556, Saudi Arabia.
| | | | - Yasmin Yousef
- King Abdullah International Medical Research Centre, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 65362, Jeddah, 21556, Saudi Arabia.,King Abdulaziz Medical City, Jeddah, Saudi Arabia
| |
Collapse
|
29
|
Khatkov IE, Maev IV, Abdulkhakov SR, Alekseenko SA, Alieva EI, Alikhanov RB, Bakulin IG, Baranovsky AY, Beloborodova EV, Belousova EA, Buriev IM, Bystrovskaya EV, Vertyankin SV, Vinokurova LV, Galperin EI, Gorelov AV, Grinevich VB, Danilov MV, Darvin VV, Dubtsova EA, Dyuzheva TG, Egorov VI, Efanov MG, Zakharova NV, Zagainov VE, Ivashkin VT, Izrailov RE, Korochanskaya NV, Kornienko EA, Korobka VL, Kokhanenko NY, Kucheryavyi YA, Livzan MA, Loranskaya ID, Nikolskaya KA, Osipenko MF, Okhlobystin AV, Pasechnikov VD, Plotnikova EY, Polyakova SI, Sablin OA, Simanenkov VI, Ursova NI, Tsvirkun VV, Tsukanov VV, Shabunin AV, Bordin DS. The Russian consensus on the diagnosis and treatment of chronic pancreatitis. TERAPEVT ARKH 2017; 89:105-113. [DOI: 10.17116/terarkh2017892105-113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
1Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow; 2A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow; 3Kazan State Medical University, Kazan; 4Kazan (Volga) Federal University, Kazan; 5Far Eastern State Medical University, Ministry of Health of Russia, Khabarovsk; 6Morozov City Children’s Clinical Hospital, Moscow Healthcare Department, Moscow; 7I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, Saint Petersburg; 8Siberian State Medical University, Ministry of Health of Russia, Tomsk; 9M.F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow; 10Maimonides State Classical Academy, Moscow; 11V.I. Razumovsky Saratov State Medical University, Saratov; 12I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow; 13S.M. Kirov Military Medical Academy, Ministry of Defense of the Russian Federation, Saint Petersburg; 14Surgut State Medical University, Ministry of Health of Russia, Surgut; 15City Clinical Hospital Five, Moscow Healthcare Department, Moscow; 16Nizhny Novgorod Medical Academy, Ministry of Health of Russia, Nizhny Novgorod; 17Territorial Clinical Hospital Two, Ministry of Health of the Krasnodar Territory, Krasnodar; 18Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint Petersburg; 19Rostov State Medical University, Ministry of Health of Russia, Rostov-on-Don; 20Omsk Medical University, Ministry of Health of Russia, Omsk; 21Russian Medical Academy of Postgraduate Education, Ministry of Health of Russia, Moscow; 22Novosibirsk State Medical University, Novosibirsk; 23Stavropol State Medical University, Ministry of Health of Russia, Stavropol; 24Kemerovo State Medical University, Ministry of Health of Russia, Kemerovo; 25N.I. Pirogov Russian Research Medical University, Ministry of Health of Russia, Moscow; 26A.M. Nikiforov All-Russian Center of Emergency and Radiation Medicine, Ministry of Emergency Situations of Russia, Saint Petersburg; 27Federal Research Center, Krasnoyarsk Research Center, Siberian Branch, Russian Academy of Sciences, Research Institute of Medical Problems of the North, Krasnoyarsk; 28S.P. Botkin City Clinical Hospital, Moscow Healthcare Department, Moscow; 29Tver State Medical University, Ministry of Health of Russia, Tver The Russian consensus (a consensus document) on the diagnosis and treatment of chronic pancreatitis has been prepared on the initiative of the Russian «Pancreatic Club» under the Delphi system. Its aim was to identify and consolidate the opinions of Russian experts on the most topical issues of the diagnosis and treatment of chronic pancreatitis. The interdisciplinary approach involved the participation of leading gastroenterologists, surgeons, and pediatricians.
Collapse
|
30
|
Thomson M, Tringali A, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, Spaander M, Hassan C, Tzvinikos C, Ijsselstijn H, Viala J, Dall'Oglio L, Benninga M, Orel R, Vandenplas Y, Keil R, Romano C, Brownstone E, Hlava Š, Gerner P, Dolak W, Landi R, Huber WD, Everett S, Vecsei A, Aabakken L, Amil-Dias J, Zambelli A. Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines. J Pediatr Gastroenterol Nutr 2017; 64:133-153. [PMID: 27622898 DOI: 10.1097/mpg.0000000000001408] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.
Collapse
Affiliation(s)
- Mike Thomson
- *International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, Weston Bank, Sheffield, UK †Digestive Endoscopy Unit, Catholic University, Rome, Italy ‡Gedyt Endoscopy Center, Buenos Aires, Argentina §Department of Pediatric Gastroenterology, Centro Hospitalar de São João, Porto, Portugal ||Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands ¶Department of Pediatric Gastroenterology and Nutrition, University Children's Hospital Basel, Basel, Switzerland #Department of Gastroenterology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands **Department of Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy ††Department of Pediatric Gastroenterology, Alder Hey Children's Hospital, Liverpool, UK ‡‡Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands §§Department of Pediatric Gastroenterology, Robert-Debré Hospital, Paris, France ||||Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital-IRCCS, Rome, Italy ¶¶Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital Ljubljana, Ljubljana, Slovenia ##Pediatric Gastroenterology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium ***Department of Gastroenterology, Motol University Hospital, Prague, Czech Republic †††Department of Pediatrics, University of Messina, Messina, Italy ‡‡‡IV Medical Department, Rudolfstiftung Hospital, Vienna, Austria §§§Department of General Pediatrics, Children's Hospital Freiburg University, Freiburg, Germany ||||||Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria ¶¶¶Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK ###Department for Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Austria ****GI Endoscopy Unit, OUS, Rikshospitalet University Hospital, Oslo, Norway ††††Gastroenterology and Digestive Endoscopy Unit, Ospedale Nuovo Robbiani di Soresina, Soresina, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Usatin D, Fernandes M, Allen IE, Perito ER, Ostroff J, Heyman MB. Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-Analysis. J Pediatr 2016; 179:160-165.e3. [PMID: 27663215 PMCID: PMC5123955 DOI: 10.1016/j.jpeds.2016.08.046] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/13/2016] [Accepted: 08/12/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To systematically review risks and summarize reported complication rates associated with the performance of endoscopic retrograde cholangiopancreatography (ERCP) in children during the past 2 decades. STUDY DESIGN A systematic literature search of MEDLINE, Embase, and Web of Science from January 1995 to January 2016 was conducted for observational studies published in English. Studies reporting ERCP complications in patients <21 years without history of liver transplant or cholecystectomy were included. A summary estimate of the proportion of children who experienced complications following ERCP was derived via a random effects meta-analysis. RESULTS Thirty-two studies involving 2612 children and 3566 procedures were included. Subjects' ages ranged from 3 days to 21 years. Procedures were performed for biliary (54%), pancreatic (38%), and other (8%) indications; 56% of ERCPs were interventional. The pooled complication rate was 6% (95% CI 4%- 8%). Procedural complications included post-ERCP pancreatitis (166, 4.7%), bleeding (22, 0.6%), and infections (27, 0.8%). The pooled estimate of post-ERCP pancreatitis was 3% (95% CI 0.02-0.05), and other complications were 1% (95% CI 0.02-0.05). In the subgroup with neonatal cholestasis, the pooled complication rate was 3% (95% CI 0.01-0.07). Adult and pediatric gastroenterologists and surgeons performed the ERCPs. Available data limited the ability to report differences between pediatric-trained and other endoscopists. CONCLUSIONS Complications associated with pediatric ERCP range widely in severity and are reported inconsistently. Our review suggests 6% of pediatric ERCPs have complications. Further studies that use systematic and standardized methodologies are needed to determine the frequency and risk factors for ERCP-related complications.
Collapse
Affiliation(s)
- Danielle Usatin
- Department of Pediatrics, University of California, San Francisco
| | | | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Emily R. Perito
- Department of Pediatrics, University of California, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - James Ostroff
- Department of Medicine, University of California, San Francisco
| | - Melvin B. Heyman
- Department of Pediatrics, University of California, San Francisco
| |
Collapse
|
32
|
Tringali A, Balassone V, De Angelis P, Landi R. Complications in pediatric endoscopy. Best Pract Res Clin Gastroenterol 2016; 30:825-839. [PMID: 27931639 DOI: 10.1016/j.bpg.2016.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/17/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.
Collapse
Affiliation(s)
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Rosario Landi
- Digestive Endoscopy Unit, Catholic University, Rome, Italy.
| |
Collapse
|
33
|
Hamidi S, Livingston MH, Alnaqi A, Yousef Y, Walton JM. Management of a massive choledochal cyst in a 12 year-old girl: Which imaging modalities should be performed preoperatively? JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
34
|
Troendle DM, Abraham O, Huang R, Barth BA. Factors associated with post-ERCP pancreatitis and the effect of pancreatic duct stenting in a pediatric population. Gastrointest Endosc 2016; 81:1408-16. [PMID: 25686874 DOI: 10.1016/j.gie.2014.11.022] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 11/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Risk factors for the development of post-ERCP pancreatitis (PEP) have not been identified in the pediatric population. It remains unclear what constitutes appropriate prophylaxis in this patient population. OBJECTIVES To assess the prevalence and severity of PEP in the pediatric population and identify factors associated with developing PEP and to evaluate the effect of prophylactic pancreatic duct stenting in high-risk patients. DESIGN Retrospective analysis of an ERCP database at a single large pediatric center. SETTING Academic center. PATIENTS A total of 432 ERCPs performed on 313 patients younger than 19 years of age from January 2004 to October 2013. INTERVENTION ERCP for any indication. MAIN OUTCOME MEASUREMENTS Rates and severity of PEP, preprocedural and procedural risk factors for the development of PEP, and the effect of pancreatic stents on preventing PEP in high-risk patients. RESULTS PEP occurred after 47 procedures (prevalence, 10.9%). Thirty-four cases were mild, 9 were moderate, and 4 were severe. There was no mortality. On multiple logistic analysis, pancreatic duct injection (P<.0001; odds ratio 30.8; 95% confidence interval [CI], 9.1-103.9) and pancreatic sphincterotomy (P<.01; OR 3.8; 95% CI, 1.6-9.8) were positively associated with PEP. A history of chronic pancreatitis was negatively associated with PEP (P<.05; OR 0.37; 95% CI, 0.15-0.93). On subset analysis, placing a prophylactic pancreatic stent was associated with significantly increased rates of PEP in patients with pancreatic duct injection compared with those who had no attempt at stent placement (P<.01). Two patients with severe pancreatitis had prophylactic pancreatic stents in place. LIMITATIONS Retrospective investigation. CONCLUSIONS In the pediatric population, pancreatic duct injection and pancreatic sphincterotomy are associated with significantly increased rates of PEP, whereas a history of chronic pancreatitis is negatively associated. Prophylactic pancreatic stenting is associated with higher rates of PEP in high-risk patients and does not eliminate severe PEP.
Collapse
Affiliation(s)
| | | | - Rong Huang
- Children's Medical Center, Dallas, Texas, USA
| | | |
Collapse
|
35
|
Yıldırım AE, Altun R, Ocal S, Kormaz M, Ozcay F, Selcuk H. The safety and efficacy of ERCP in the pediatric population with standard scopes: Does size really matter? SPRINGERPLUS 2016; 5:128. [PMID: 26933627 PMCID: PMC4760957 DOI: 10.1186/s40064-016-1749-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 02/12/2016] [Indexed: 02/07/2023]
Abstract
Experience with endoscopic retrograde cholangiopancreatography in the pediatric population is limited. The aim of this study was to evaluate the outcomes of ERCP in the pediatric population performed by adult gastroenterologists with standard duodenoscopes. This study is a structured retrospective review of endoscopic reports, computerized and paper medical records, and radiographic images of patients under the age of 18 who underwent ERCP for any indication at a tertiary referral centre. Data regarding demographic characteristics and medical history of patients, indications, technical success rate, final clinical diagnosis, and complications were analyzed. Forty-eight children with a mean age of 13 years (range 2–17) underwent a total of 65 ERCPs. The indications of ERCP were as follows; suspected choledocholithiasis (55 %), post-liver transplantation anastomotic biliary strictures (21 %), post-surgical bile duct injury (10 %), choledochal cyst (2 %), recurrent or chronic pancreatitis (10 %), and trauma (2 %). The cannulation success rate in the overall procedure was 93.8 %. Therapeutic interventions were performed in 70.7 % of patients. Post ERCP pancreatitis was the most common complication occurring in 9.2 % of patients, and no procedure related mortality occurred. When performed by well-trained adult gastroenterologists, the use of endoscopic retrograde cholangiopancreatography with standard duodenoscopes is safe in pediatric population.
Collapse
Affiliation(s)
- Abdullah Emre Yıldırım
- Department of Gastroenterology, Faculty of Medicine, Başkent University, 06500 Bahcelievler, Ankara, Turkey
| | - Reskan Altun
- Department of Gastroenterology, Faculty of Medicine, Başkent University, 06500 Bahcelievler, Ankara, Turkey
| | - Serkan Ocal
- Department of Gastroenterology, Faculty of Medicine, Başkent University, 06500 Bahcelievler, Ankara, Turkey
| | - Murat Kormaz
- Department of Gastroenterology, Faculty of Medicine, Başkent University, 06500 Bahcelievler, Ankara, Turkey
| | - Figen Ozcay
- Department of Pediatric Gastroenterology, Faculty of Medicine, Başkent University, Ankara, Turkey
| | - Haldun Selcuk
- Department of Gastroenterology, Faculty of Medicine, Başkent University, 06500 Bahcelievler, Ankara, Turkey
| |
Collapse
|
36
|
Berent A, Weisse C, Schattner M, Gerdes H, Chapman P, Kochman M. Initial experience with endoscopic retrograde cholangiography and endoscopic retrograde biliary stenting for treatment of extrahepatic bile duct obstruction in dogs. J Am Vet Med Assoc 2015; 246:436-46. [PMID: 25632818 DOI: 10.2460/javma.246.4.436] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe techniques for endoscopic retrograde cholangiography (ERC) and endoscopic retrograde biliary stenting of the common bile duct (CBD) for minimally invasive treatment of extrahepatic bile duct obstruction (EHBDO) in dogs. DESIGN Experimental study and clinical report. ANIMALS 7 healthy research dogs and 2 canine patients. PROCEDURES ERC and endoscopic retrograde biliary stenting were performed in healthy purpose-bred research dogs and client-owned dogs with a diagnosis of EHBDO that underwent an attempted biliary stent procedure. Research dogs were euthanized after completion of the procedure and underwent necropsy. With dogs under general anesthesia, the pylorus was cannulated with a side-view duodenoscope, and the duodenum was entered. The major duodenal papilla (MDP) and minor duodenal papilla were then identified, and the MDP was cannulated. Endoscopic retrograde cholangiography and endoscopic retrograde biliary stenting were attempted with the aid of endoscopy and fluoroscopy in all dogs. Procedure time, outcome for duodenal and MDP cannulation, and success of stent placement were recorded. RESULTS Endoscopic retrograde cholangiography was successfully performed in 5 of 7 research dogs and in 1 of 2 patients. Biliary stenting was achieved in 4 of 7 research dogs and 1 of 2 patients, with a polyurethane (n = 4) or self-expanding metallic stent (1). One patient had a mass such that visualization of the MDP was impossible and no attempt at biliary cannulation could be made. After placement, stent patency was documented by means of contrast cholangiography and visualization of biliary drainage into the duodenum intra-operatively. No major complications occurred during or after the procedure in any patient. Follow-up information 685 days after stent placement in 1 patient provided evidence of biliary patency on serial repeated ultrasonography and no evidence of complications. CONCLUSIONS and CLINICAL RELEVANCE ERC and endoscopic retrograde biliary stenting were successfully performed in a small group of healthy dogs and 1 patient with EHBDO, but were technically challenging procedures. Further investigation of this minimally invasive technique for the treatment of EHBDO in dogs is necessary before this may be considered a viable alternative to current treatment methods.
Collapse
Affiliation(s)
- Allyson Berent
- Department of Diagnostic Imaging and Interventional Radiology, Animal Medical Center, 510 E 62nd St, New York, NY 10065
| | | | | | | | | | | |
Collapse
|
37
|
ESPGHAN and NASPGHAN Report on the Assessment of Exocrine Pancreatic Function and Pancreatitis in Children. J Pediatr Gastroenterol Nutr 2015; 61:144-53. [PMID: 25915425 DOI: 10.1097/mpg.0000000000000830] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this clinical report is to discuss several recent advances in assessing exocrine pancreatic insufficiency (EPI) and pancreatitis in children, to review the array of pancreatic function tests, to provide an update on the inherited causes of EPI, with special emphasis on newly available genetic testing, and to review newer methods for evaluating pancreatitis.
Collapse
|
38
|
Kieling CO, Hallal C, Spessato CO, Ribeiro LM, Breyer H, Goldani HAS, Maguilnik I. Changing pattern of indications of endoscopic retrograde cholangiopancreatography in children and adolescents: a twelve-year experience. World J Pediatr 2015; 11:154-9. [PMID: 25410666 DOI: 10.1007/s12519-014-0518-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are few data regarding endoscopic retrograde cholangiopancreatography (ERCP) usefulness in children and adolescents. We reviewed the long-term experience with diagnostic and therapeutic ERCP in a tertiary single center in Southern Brazil. METHODS A retrospective chart review of patients aged 0-18 years who had undergone ERCPs from January 2000 to June 2012 was done. Data on demographics, indications, diagnosis, treatments, and complications were collected. RESULTS Seventy-five ERCPs were performed in 60 patients. The median age of the patients at the procedure was 13.9 years (range: 1.2-17.9). Of the 60 patients, 47 (78.3%) were girls. Of all ERCPs, 48 (64.0%) were performed in patients above 10 years and 35 (72.9%) of them were in girls. ERCP was indicated for patients with bile duct obstruction (49.3%), sclerosing cholangitis (18.7%), post-surgery complication (12%), biliary stent (10.7%), choledochal cyst (5.3%), and pancreatitis (4%). The complication rate of ERCP was 9.7% involving mild bleeding, pancreatitis and cholangitis. Patients who had therapeutic procedures were older (13.7±3.9 vs. 9.9±4.9 years; P=0.001) and had more extrahepatic biliary abnormalities (82% vs. 50%; P=0.015) than those who had diagnostic ERCPs. A marked change in the indications of ERCPs was found, i.e., from 2001 to 2004, indications were more diagnostic and from 2005 therapeutic procedures were predominant. CONCLUSIONS Diagnostic ERCPs are being replaced by magnetic resonance cholangiopancreatography and also by endoscopic ultrasound. All these procedures are complementary and ERCP still has a role for therapeutic purposes.
Collapse
Affiliation(s)
- Carlos O Kieling
- Post-Graduate Program of Sciences in Gastroenterology and Hepatology, Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Brazil
| | | | | | | | | | | | | |
Collapse
|
39
|
Giefer MJ, Kozarek RA. Technical outcomes and complications of pediatric ERCP. Surg Endosc 2015; 29:3543-50. [PMID: 25673350 DOI: 10.1007/s00464-015-4105-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 01/28/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Previous reports have suggested that endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients is safe, but because the total number of cases reported in the literature remains small, questions remain regarding safety and outcomes of this procedure in children. METHODS Pediatric patients who underwent ERCP were identified from diagnostic to billing codes. Medical records were examined for age, gender, diagnosis codes, indication, type of sedation, findings, interventions, and complications. Descriptive statistics were prepared for data including frequencies, percentages for categorical variables, and means and standard deviations for quantitative variables. Extensions of logistic regression were used to examine the relationship between demographic and clinical characteristics and post-ERCP pancreatitis. RESULTS Four hundred and twenty-five ERCPs were performed on 276 pediatric patients. Patient's age ranged from 72 days to 18 years, and there was equal gender distribution. Targeted duct cannulation was achieved in over 95% of cases, and therapeutic interventions were common (81.3%). The most common indications were biliary obstruction (43.3%) and chronic pancreatitis (26.8%). The most common complication was post-ERCP pancreatitis which occurred in 26 cases (7.7%), and the majority was mild by consensus definition. Procedural characteristics significantly associated with post-ERCP pancreatitis included: pancreatogram, pancreatic sphincterotomy, pancreatic duct stenting, and pancreatic duct stricture dilation. Immediate post-sphincterotomy bleeding occurred twice (1.1%), and both cases were successfully treated during the procedure. There was one instance of a possible delayed sphincterotomy bleed. No mortality was observed. CONCLUSIONS This retrospective review is one of the larger ERCP series reported in the pediatric population and adds to the growing body of literature supporting that ERCP can be safely applied in younger patients by skilled endoscopists. The complication rate found in this series closely parallels that observed in adults. Prospective studies of pediatric ERCP are still required to more definitively define the safe and appropriate use of this procedure in children.
Collapse
Affiliation(s)
- Matthew J Giefer
- Pediatrics - Gastroenterology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Richard A Kozarek
- Digestive Disease Institute at Virginia Mason Medical Center, Seattle, WA, 98105, USA
| |
Collapse
|
40
|
Hatlani MA, Kortan P, May G, Ling SC, Walters T, Avitzur Y. Wire-guided cannulation versus contrast-guided cannulation in pediatric endoscopic retrograde cholangiopancreatography. Saudi J Gastroenterol 2015; 21:25-9. [PMID: 25672235 PMCID: PMC4355858 DOI: 10.4103/1319-3767.151219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIM Wire-guided cannulation (WGC) of the common bile duct may be associated with fewer complications and higher success rate compared with contrast-guided cannulation (CGC) in adults. Data in children are lacking. The aim of this study was to compare the successful cannulation and complication rate of WGC and CGC in pediatric endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS We report a retrospective cohort study comparing WGC to CGC in a pediatric cohort. We reviewed the medical records of 167 children who underwent ERCP over a 10-year time period (CGC, 1999-2003, WGC, 2003-2009). Indications, findings, and success were analyzed. RESULTS A total of 93 patients (56%) underwent WGC and 74 (44%) CGC. Children in the WGC group were younger (9.5 ± 4.7 vs. 11.5 ± 4.6 years in CGC; P = 0.006) and underwent more therapeutic ERCP interventions (70% vs. 40% in CGC), whereas diagnostic ERCP was more common in the CGC group (60%; P < 0.005). The overall success (96%) and complication rate (8%) were identical in both groups but a trend toward a reduction in the complication rate over time was noted in the WGC group. Post-ERCP pancreatitis (PEP) was documented in one patient in the WGC group (1.1%) and three patients (4.2%) in the CGC group (P-NS). CONCLUSION The success and complication rate in both CGC and WGC are comparable in children but considering the patient and procedure complexity and the trend toward lower PEP in the WGC group, WGC may be the preferable cannulation technique for ERCP in children.
Collapse
Affiliation(s)
- Maher Al Hatlani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada,Department of Pediatrics and KAIMRC, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia,Address for correspondence: Dr. Maher Mohammed Al Hatlani, Division of Gastroenterology, Hepatology and Nutrition, King Abdulaziz Medical City, Ministry of National Guard, Prince Miteb Bin Abdulaziz Road, Riyadh 11426 P.O Box 22490, Saudi Arabia. E-mail:
| | - Paul Kortan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gary May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Thomas Walters
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| |
Collapse
|
41
|
Hill SJ, Wulkan ML, Parker PM, Jones TK, Heiss KF, Clifton MS. Management of the Pediatric Patient with Choledocholithiasis in an Era of Advanced Minimally Invasive Techniques. J Laparoendosc Adv Surg Tech A 2014; 24:38-42. [DOI: 10.1089/lap.2013.0306] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Sarah J. Hill
- Emory University School of Medicine, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mark L. Wulkan
- Emory University School of Medicine, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Tram K. Jones
- Emory University School of Medicine, Atlanta, Georgia
| | - Kurt F. Heiss
- Emory University School of Medicine, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew S. Clifton
- Emory University School of Medicine, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
| |
Collapse
|
42
|
Lau BJ, Sydorak RM, Shaul DB. Laparoscopic techniques for safe and successful removal of common bile duct stones in pediatric patients. J Laparoendosc Adv Surg Tech A 2013; 24:362-5. [PMID: 24195783 DOI: 10.1089/lap.2013.0174] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND/PURPOSE Choledocholithiasis is uncommon in the pediatric population. Techniques for common bile duct stone extraction are still not well established. This article aims to describe safe and applicable techniques for pediatric common bile duct exploration. MATERIALS AND METHODS This was a retrospective review of a prospectively maintained database of two pediatric surgeons for patients undergoing laparoscopic common bile duct exploration at two tertiary-care centers from April 2008 to March 2012. RESULTS For 39 patients under 15 years of age undergoing laparoscopic cholecystectomy, 10 cholangiograms were performed, and 8 were found to have filling defects. Seven patients underwent successful laparoscopic common bile duct exploration with documentation of stone clearance, and 1 patient was sent for postoperative endoscopic retrograde cholangiopancreatography with stone extraction. Eleven patients had cholecystectomy performed by single-incision laparoscopic surgery, but none of these had cholangiograms or common bile duct explorations. Various methods of stone clearance were used, including the use of saline flush, balloon catheters, nitinol stone extractors, and the aide of glucagon. Depending on patient size, a choledochosope or a ureteroscope was used. There were no complications and no conversions to open surgery. CONCLUSIONS Laparoscopic common bile duct exploration is feasible in the pediatric population, using many of the instruments readily available in the standard operating room. With an armamentarium of tools and techniques, the method of stone extraction can be tailored to the patient and situation.
Collapse
Affiliation(s)
- Briana J Lau
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
| | | | | |
Collapse
|
43
|
Endoscopic retrograde cholangiopancreatography in the pediatric population is safe and efficacious. J Pediatr Gastroenterol Nutr 2013; 57:649-54. [PMID: 23760230 DOI: 10.1097/mpg.0b013e31829e0bb6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being used in the evaluation and management of biliary and pancreatic disorders in children. The aim of this study was to review the pediatric ERCP experience of a large academic referral center affiliated with a tertiary care children's hospital. METHODS This is a retrospective review of medical records, endoscopic and operative reports, and radiography of those patients ages 0 to 21 years who underwent ERCP for any indication between 1993 and 2011 at a tertiary referral center affiliated with a large urban pediatric hospital. ERCP technical success was defined as cannulation of the desired duct. Serious adverse events included bleeding, perforation, pancreatitis, or death. RESULTS Four hundred twenty-nine ERCPs were performed on 296 patients. The mean age was 14.9 ± 4.8 years (3 months-21 years); 51.1% were boys. Patients with a history of previous liver transplant comprised 13.1% (56) of all ERCPs. Abnormal liver chemistries or suspected choledocholithiasis accounted for half of the indications. A therapeutic intervention was performed in 64.1%. Technical success was achieved in 95.2% of ERCPs. Serious adverse events occurred in 7.7%. CONCLUSIONS Pediatric ERCP is highly efficacious in the pediatric population, with the rates of technical success and use of therapeutic interventions mirroring those in adults. There is a low overall rate of serious adverse events. The overall efficacy and safety support the performance of pediatric ERCP by experienced endoscopists at high-volume centers.
Collapse
|
44
|
ERCP can be safely and effectively performed by a pediatric gastroenterologist for choledocholithiasis in a pediatric facility. J Pediatr Gastroenterol Nutr 2013; 57:655-8. [PMID: 24048163 DOI: 10.1097/mpg.0000000000000124] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to demonstrate that an appropriately trained pediatric gastroenterologist can perform endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis both safely and effectively. METHODS Retrospective analysis of ERCP experience from November 2006 to May 2012. Only ERCPs performed by a pediatric gastroenterologist on pediatric patients for the indication of suspected choledocholithiasis were included for formal chart review. Patient characteristics, procedural success, and adverse events were recorded, and subsequently compared with quality standards as defined by the American Society for Gastrointestinal Endoscopy Quality Task Force. RESULTS A total of 154 ERCPs were performed, of which 65 (42%) were performed on unique patients for the indication of suspected choledocholithiasis. The median age was 15.2 years (range 1 month-18.4 years). The median weight was 65 kg (range 4-127 kg). Biliary cannulation was achieved in 65 (100%). All 65 patients underwent sphincterotomy. Ductal clearance was achieved in 64 (98%) patients during the initial ERCP session. Adverse events included 3 (5%) episodes of mild pancreatitis, 1 episode of moderate bleeding, and 1 episode of sphincterotomy clot causing obstruction and need for repeat ERCP within 1 week. Overall, 5 (8%) unique patients experienced a complication. CONCLUSIONS Therapeutic ERCP for the indication of choledocholithiasis can be performed by an appropriately trained pediatric gastroenterologist at a pediatric facility with acceptable cannulation rates, stone extraction rates, and adverse event rates as defined by the American Society for Gastrointestinal Endoscopy Quality Task Force.
Collapse
|
45
|
Comparison of performance and safety of endoscopic retrograde cholangiopancreatography across pediatric age groups. Dig Dis Sci 2013; 58:2653-60. [PMID: 23709156 DOI: 10.1007/s10620-013-2691-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 04/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIM Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be overall effective and safe in children, but its performance characteristics and safety profile have not been specifically evaluated according to age. We aim to compare the indications, findings, interventions, and safety outcomes of ERCP across pediatric age groups. METHODS A retrospective cross-sectional study of pediatric patients (ages 17 or below) who underwent ERCP between October 1998 and April 2011 at a tertiary-care academic center. Data on indications, findings, technical success, and adverse events of ERCP were collected and compared according to age groups (0-6, 7-12, or 13-17 years). RESULTS There were 289 procedures performed in 154 children (mean age, 11.5 years). The number of patients undergoing ERCP increased with age; teenagers constituted the largest group (52.6%) and had the most procedures (49.8%). Children aged 0-6 years had an equal distribution of biliary and pancreatic cases; children aged 7-12 years had predominantly pancreatic indications. Most procedures in teenagers were for biliary indications. Overall, the technical success rates of ERCPs were similar across age groups (P=0.661). Seventeen adverse events (5.9% of procedures) were identified: post-procedure pancreatitis (12 cases; 4.2%), hypoxia (3; 1.0%), and hemorrhage (2; 0.7%). The youngest group had more adverse events (12.0%, compared to 6.3 and 2.1% in other groups; P=0.049), mostly due to mild pancreatitis. CONCLUSION ERCP is generally safe in the pediatric population, although the risk of mild post-procedure pancreatitis may be higher among the youngest children.
Collapse
|
46
|
Steen MW, Bakx R, Tabbers MM, Wilde JCH, van Lienden KP, Benninga MA, Heij HA, Rauws EAJ. Endoscopic management of biliary complications after partial liver resection in children. J Pediatr Surg 2013; 48:418-24. [PMID: 23414877 DOI: 10.1016/j.jpedsurg.2012.10.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 08/24/2012] [Accepted: 10/01/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Biliary complications after liver surgery are difficult to manage. Endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the common bile duct is not commonly practiced in children for this purpose. The aim of this retrospective review is to evaluate the role of ERCP as both a diagnostic and a therapeutic tool in the management of biliary complications after liver resection in children. PATIENTS AND METHODS The charts of all patients from 0 to 18 years old who underwent partial liver resection in a tertiary children's hospital in Amsterdam, the Netherlands, between 2000 and 2010 were retrospectively reviewed. RESULTS Forty-five children (median age: 3.6 years, range: 2 months-17 years) underwent partial liver resection. Post-operative biliary complications occurred in 13 children. Ten patients were suffering from bile leakage. Eight of them underwent ERCP with stent placement after which leakage stopped in 5 patients. Three patients presented with a post-operative biliary tract stricture. ERCP with dilation and stent placement was performed in 2 of them, which solved the problem in one patient. ERCP demonstrated the nature (bile leak and/or biliary tract stricture(s)), extent, and location of the lesion in 8 of 10 children. There were no serious procedure related complications. Rescue procedures in the other patients included hepaticojejunostomy and liver transplant. CONCLUSION ERCP with stenting of the common bile duct has a diagnostic and therapeutic role in the management of bile leaks after partial liver resection in children. The value of ERCP in the management of a stricture of the biliary tract is less conclusive.
Collapse
Affiliation(s)
- Mette W Steen
- Paediatric Surgical Centre of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Short SS, Frykman PK, Nguyen N, Liu Q, Berel D, Wang KS. Laparoscopic common bile duct exploration in children is associated with decreased cost and length of stay: results of a two-center analysis. J Pediatr Surg 2013; 48:215-20. [PMID: 23331818 DOI: 10.1016/j.jpedsurg.2012.10.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 10/13/2012] [Indexed: 01/01/2023]
Abstract
PURPOSE Our aim was to compare outcomes of children undergoing laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC+CBDE) to those undergoing laparoscopic cholecystectomy with adjunctive endoscopic retrograde cholangiopancreatography (LC+ERCP). METHODS We performed a two-center retrospective chart review of all children (<18 years) undergoing LC+CBDE or LC+ERCP between January 2000 and July 2011. Wilcoxon test was performed on continuous variables and logistic regression modeling on categorical data. A P value < 0.05 was considered significant. Outcomes with a P value < 0.2 were selected for multivariable analysis. RESULTS Forty-two patients were identified. Twenty-four (57%) underwent LC+ERCP, and eighteen (43%) underwent LC+CBDE. Demographic and clinical factors were well matched between groups. Total operative time was similar between groups (157 min vs. 152 min, P = .26). LC+CBDE patients had zero major complications and five minor complications (retained stone: 3, pancreatitis: 1, late recurrence: 1). LC+ERCP patients experienced two major complications (duodenal perforation: 1, bleeding requiring transfusion: 1), and four minor complications (pancreatitis: 2, retained stone: 2, P = .57). Median length of stay was significantly longer (15.7 days vs. 6.6 days, P = .02), and median hospital cost was significantly higher ($18,132 vs. $12,735, P < .01) in the LC+ERCP group. Multivariable analysis revealed that cost was significantly lower in patients undergoing LC+CBDE (P = .05, OR= 0.71; 95% CI: 0.51-0.97). CONCLUSION LC+CBDE at the time of cholecystectomy is associated with decreased length of stay, decreased cost, and has similar or improved morbidity compared to LC+ERCP.
Collapse
|
48
|
Laparoscopic cholecystectomy in children with sickle cell anemia and the role of ERCP. Surg Laparosc Endosc Percutan Tech 2012; 22:139-42. [PMID: 22487628 DOI: 10.1097/sle.0b013e3182471b1c] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with sickle cell anemia (SCA) have a high incidence of cholelithiasis and choledocholithiasis. This report is an analysis of our experience with laparoscopic cholecystectomy (LC) for children with SCA and the role of endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS The records of children with SCA who had cholecystectomy were retrospectively reviewed for age, sex, hemoglobin level, hemoglobin electrophoresis, indication for cholecystectomy, operative time, hospital stay, and postoperative complications. They were divided into 2 groups, open cholecystectomy (OC) group and LC group, and the 2 were compared in terms of operative time, hospital stay, and postoperative complications. RESULTS Over a period of 15 years (January 1995 and December 2009), 94 children with SCA had cholecystectomy. Thirty-five (19 males and 16 females) had OC, 52 (28 males and 24 females) had LC, and 7 (4 males and 3 females) had LC and splenectomy. Their age ranged from 4 to 15 years (mean, 11.4 y). The indications for cholecystectomy were biliary dyspepsia and biliary colic (55), acute cholecystitis (7), obstructive jaundice (17), asymptomatic (12), and biliary pancreatitis (3). All those who had OC underwent intraoperative cholangiogram, 9 of them (25.7%) had common bile duct (CBD) exploration and 2 transduodenal sphincterotomy. Of those who had LC, 13 (25%) underwent preoperative ERCP, which was normal in 1, showed dilated CBD with no stones in 2, and dilated CBD with stones in 7. In 3, ERCP showed dilated CBD with enlarged, inflammed papilla suggestive of recent stone passage. Nine underwent endoscopic sphincterotomy and stone extraction followed by LC. There was no mortality; 1 (2.1%) required conversion to OC and another underwent postoperative exploration because of bleeding from an accessory cystic artery. In the LC group, 4 (7.7%) developed minor postoperative complications, whereas 8 (22.9%) in the OC group developed complications. CONCLUSIONS With proper perioperative management, LC is feasible, safe, and superior to OC in children with SCA with regard to postoperative complications, duration of hospital stay, cosmetic appearance, and postoperative recovery. LC should be the treatment of choice for both symptomatic and asymptomatic cholelithiasis in children with SCA. ERCP is a valuable diagnostic and therapeutic investigation both preoperatively and postoperatively. The sequential approach of endoscopic sphincterotomy and stone extraction followed by LC is a safe and effective approach for the management of cholelithiasis and choledocholithiasis in children with SCA.
Collapse
|
49
|
Menon S, Patel B, Saekang E, Thomas G, Soundappan S, Shun A. Laparoscopic exploration of the common bile duct to relieve choledocholithiasis in children. Pediatr Surg Int 2011; 27:537-40. [PMID: 21290137 DOI: 10.1007/s00383-010-2826-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE The optimal method of managing paediatric choledocholithiasis is controversial. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are effective in adults; however, the long-term outcome in the paediatric population is unknown. We report our experience with laparoscopic common bile duct (CBD) exploration to relieve choledocholithiasis in children and propose a management algorithm. METHODS A retrospective chart review of 124 children, who underwent cholecystectomy over 5 years was conducted. Data collected included age at onset, duration of symptoms, length of stay, method of relieving choledocholithiasis and postoperative outcome. RESULTS Mean age was 12.5 years (range 10-14 years). 102 cholecystectomies were performed laparoscopically. Following intraoperative cholangiogram (IOC), choledocholithiasis was identified in eight patients. In three cases, the CBD was flushed with normal saline via a 5F ureteral catheter successfully relieving the obstruction. In three cases, a Dormia basket was used to break down the stone. Two cases required postoperative ERCP and sphincterotomy to successfully extract the stones. All children were symptom-free at follow-up with no complications reported to date. CONCLUSION Laparoscopic CBD exploration with Dormia basket or saline flushes to relieve choledocholithiasis is a safe and effective alternative in children. If unsuccessful, ERCP and sphincterotomy can be performed in centres with adequate resources and expertise.
Collapse
Affiliation(s)
- Seema Menon
- Department of Paediatric Surgery, Sydney Childrens' Hospitals Network, Westmead Campus, Sydney, NSW, 2145, Australia.
| | | | | | | | | | | |
Collapse
|
50
|
Osanai M, Maguchi H, Takahashi K, Katanuma A, Yane K, Kaneko M, Hashigo S, Katoh S, Harada R, Katoh R, Tanno S. Safety and long-term outcomes of endoscopic papillary balloon dilation in children with bile duct stones. Gastrointest Endosc 2011; 73:619-23. [PMID: 21237459 DOI: 10.1016/j.gie.2010.10.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 10/27/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although experience with diagnostic and therapeutic ERCP in children is growing, little is known about the safety and technical outcomes of endoscopic papillary balloon dilation (EPBD) in pediatric patients with bile duct stones (BDSs). OBJECTIVE To assess the safety and long-term outcomes of EPBD in pediatric patients with BDSs. DESIGN Case study. SETTING Tertiary referral center. PATIENTS AND INTERVENTIONS This study involved 5 children who had BDSs combined with gallstones who underwent EPBD. MAIN OUTCOME MEASUREMENTS Successful EPBD, successful stone removal, procedure-related complications, and long-term outcomes. RESULTS ERCP was successful in all cases, with cannulation and subsequent EPBD. Stone removal was performed in 1 session in all patients. No EPBD-related complications were observed in any patient. After EPBD, 1 patient subsequently underwent laparoscopic cholecystectomy for gallstones. The remaining 4 were followed without surgery. In 2 patients, gallstones were spontaneously passed from the bile duct into the duodenum. During the follow-up period, over a mean of 7.1 years (range 3.7-9.3 years), no recurrence of BDSs was observed in any patient. LIMITATIONS Small number of patients. CONCLUSIONS Although BDSs are rare in pediatric patients, EPBD may be a safe and effective technique for the management of such stones in some children.
Collapse
Affiliation(s)
- Manabu Osanai
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|