Endoscopic retrograde cholangiopancreatography is useful and safe in children

Availability and utilization of endoscopic retrograde cholangiopancreatography at children's hospitals

OBJECTIVES

No study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors.

METHODS

Healthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service.

RESULTS

From 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available.

CONCLUSIONS

One-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care.

Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis

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.

Application of imaging techniques in pancreaticobiliary maljunction

Imaging techniques are useful tools in the diagnosis and treatment of pancreaticobiliary maljunction (PBM). PBM is a precancerous lesion often relative to the disease of the pancreas and biliary tract, for example, cholecystolithiasis, protein plugs, and pancreatitis. For patients with PBM, early diagnosis and timely treatment are highly important, which is largely dependent on imaging techniques. The continuous development of imaging techniques, including endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, computed tomography, ultrasound, and intraoperative cholangiography, has provided appropriate diagnostic and therapeutic tools for PBM. Imaging techniques, including non-invasive and invasive, have distinct advantages and disadvantages. The purpose of this paper is to review the application of various imaging techniques in the diagnosis and treatment of PBM.

Utility of endoscopic retrograde cholangiopancreatography in infant patients with conservational endoscopy

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.

A Case of Congenital Common Bile Duct Web Treated with Balloon Dilation under Endoscopic Retrograde Cholangiopancreatography in a Young Child

Web in common bile duct (CBD web) is very rare. It is usually asymptomatic and detected incidentally during surgery for other causes in adults. It can be congenital or acquired, however congenital CBD web is extremely rare. Currently, despite its invasiveness and complications, endoscopic retrograde cholangiopancreatography (ERCP) is considered as a useful diagnostic and therapeutic modality in children with hepatobiliary pancreatic diseases as in adults. Herein we report a case of congenital CBD web presenting with acute pancreatitis and choledocholithiasis in a 4-year-old girl which was diagnosed and treated using balloon dilation under ERCP. After balloon dilation of the web, a common pancreatobiliary channel was observed. To the best of our knowledge, a case of congenital CBD web with pancreatobiliary junctional abnormality treated using ERCP in a child has not been reported to date.

Retrospective Multicenter Matched Controlled Comparison of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients: A 10-year Experience

INTRODUCTION

This study was designed to evaluate outcomes in pediatric patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) as compared with an American Society of Gastrointestinal Endoscopy (ASGE) complexity grade-matched adult cohort.

METHOD

In this retrospective case-control study, ERCPs performed in pediatric patients from January 2008 to December 2018 in 2 tertiary referral hospitals were compared with a complexity-matched adult control group with similar procedural indications. Primary outcomes included the clinical success rate, technical success rate, and complication rate. Secondary outcomes included postprocedural admission rates, mode of sedation, procedure time, fluoroscopy time, hospitalization length, and the number of repeat procedures.

RESULTS

Two hundred thirty-two ERCPs performed in 110 pediatric patients (average age 13.3) and 318 ERCPs performed in 160 ASGE grade-matched adult controls (average age 47.2 years) were analyzed. All procedures were therapeutic. There was no difference in the technical success rate (P = 0.2), clinical success rate (P = 0.5), complication rates (P = 0.1), and fluoroscopy time (P = 0.4), between the pediatric and adult cohorts. General anesthesia use and length of stay were significantly higher in the pediatric group (P = 0.0001). In subgroup analysis, technical (P = 0.2) and clinical success (P = 0.2) as well as complication rates (P = 0.6) were comparable between patients 10 years or less and patients 11 to 18 years within pediatric cohort.

CONCLUSIONS

ERCP in pediatric cohorts appears to be safe and effective with equivalent outcomes relative to an ASGE complexity-matched adult cohort. Pediatric patients are more likely to require general anesthesia and have a longer average length of stay relative to adult controls.

Pediatric Endoscopy, Update 2020

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.

"Rendezvous" Procedure in Children with Cholecysto-Choledocholithiasis

Introduction: Cholecysto-choledocolithiasis is a rare entity in children and its management is still challenging and controversial. The laparoendoscopic rendezvous (LERV) procedure, consisting of laparoscopic cholecystectomy and simultaneous endoscopic retrograde cholangiopancreatography for the management of symptomatic choledocholithiasis is well described in adult patients. However, in the literature, few reports about its application in the pediatric population have been recorded. Aim of the Study: The aim of the present study is to report our first successful cases of symptomatic cholecysto-choledocholithiasis LERV treatment. Methods: Two girls suffering of hemolytic disease presented to our third referral center with acute abdominal pain due to cholecysto-choledocholithiasis. Preoperative, perioperative, and postoperative data were retrospectively reviewed. Results: Surgery was performed without complications. The girls were dismissed once re-alimentation and re-canalization were achieved and had no other episodes of biliary cholic. Reported advantages of LERV include: a shorter in-hospital stay, a reduction in the number of procedures and anesthesia, and a reduced overall risk of complications. Conclusions: The promising result with our 2 cases suggest that, when performed in highly specialized centers, LERV is a safe procedure, which leads to considerable benefits, despite logistic and organizational difficulties.

ERCP in infants, children, and adolescents-Different roles of the methods in different age groups

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is seldom used in children, and published series have limited numbers of pediatric patients. The aim of this retrospective observational study was to assess the efficacy and safety of pediatric ERCP in a large group of children.

METHODS

Data were evaluated from 626 children with biliopancreatic disorders admitted to University Hospital Motol, Prague, between January 1999 and January 2018. Clinical data were obtained by retrospective evaluation of our database of pediatric ERCP procedures and from clinical records.

RESULTS

We performed 856 ERCPs on 626 pediatric patients; of these procedures, 59% were therapeutic and 41% were diagnostic. We achieved 96% technical success. Indications for ERCP and pathological findings differed in different age groups. The main role of ERCP was in excluding biliary atresia in those aged less than one year. In children aged 1 to 6 years, the most frequent diagnoses were choledochal cyst followed by choledocholithiasis. In children aged 7 to 12 years and 13 to 19 years, the most frequent diagnoses were choledocholithiasis followed by pancreatic pathology. The overall complication rate found in this study was similar to rates observed in adult populations.

CONCLUSIONS

Our study shows the efficacy and safety of diagnostic and therapeutic ERCP in a large series of infants and children with technical success and complication rates comparable to those in adults. Our data show that ERCP had different roles in different age groups of children.

Endoscopic retrograde cholangiopancreatography in children: Retrospective series with a long-term follow-up and literature review

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.

Endoscopic biliary drainage management for children with serious cholangitis caused by congenital biliary dilatation

Congenital biliary dilatation (CBD) is usually associated with complications such as recurrent cholangitis, manifested as abdominal pain, vomiting, and jaundice. If cholangitis cannot be controlled by conservative treatment, a good therapeutic effect can be obtained through percutaneous biliary drainage or open T-tube drainage. We aimed to evaluate our experiences in biliary drainage through endoscopic retrograde cholangiopancreatography in children with cholangitis caused by CBD. From January 2014 to December 2017, 167 children with CBD were treated in our hospital. 17 patients (10.18%) with serious cholangitis caused by CBD underwent ERCP. There were 4 males and 13 females with an age range of 10-120 months (average 56.4 months). Placement of a biliary stent was attempted for biliary drainage through endoscopic retrograde cholangiopancreatography. Of the 17 patients studied, 13 children had jaundice and 15 had elevated aminotransferases. ERCP showed CBD in all patients and a common biliopancreatic duct in 12 of 17 patients (70.6%). Five patients underwent nasobiliary drainage and 12 patients underwent biliary drainage through double pigtail tubes. All patients achieved successful biliary drainage. Postoperative pancreatitis occurred in one patient. Biochemical indicators decreased significantly in 12 patients (70.6%) on the second postoperative day. The average length of hospital stay after surgery was 4.5 (range 3-7) days. No major complications related to ERCP were observed and all children had a good prognosis so far. Endoscopic biliary drainage is a safe, simple, and reliable technique. It can be used to resolve CBD-associated cholangitis, evaluate the biliary tract and pancreatobiliary duct junction, and guide pediatric surgeons to choose the right time and the correct procedure for CBD.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

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.

Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-Analysis

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.

The safety and efficacy of ERCP in the pediatric population with standard scopes: Does size really matter?

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.

Changing pattern of indications of endoscopic retrograde cholangiopancreatography in children and adolescents: a twelve-year experience

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.

Technical outcomes and complications of pediatric ERCP

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.

Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children

BACKGROUND

The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children.

METHODS

All children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up.

RESULTS

551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5%) presented with CBD stones with a mean age at symptom onset of 10.4 years (min-max: 4 months-18 years). A majority of the patients presented with hemolytic disease (61%). In 55% of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72% of success rate. In 9 cases (25%) of failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2 years (min-max: 1 month-5 years). All patients were stone free at last clinical and radiological evaluation.

CONCLUSION

A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72% of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children.

Role of pediatric endoscopic retrograde cholangiopancreatography in an era stressing less-invasive imaging modalities

BACKGROUND

The significance of pediatric endoscopic retrograde cholangiopancreatography (ERCP) according to age or disease variation is inconclusive. This study aimed to evaluate the usefulness of pediatric ERCP in diagnosing or treating small children with pancreaticobiliary disorders, including choledochal cyst (CC) and biliary atresia (BA).

METHODS

From 1980 to 2011, 235 ERCPs were performed in 220 pediatric patients (median age, 2 years) at our institution. Underlying pathology was CC in 92 patients (3 years), BA in 62 patients (55 days), and others in 66 patients. Success and complication rates, and ERCP findings were retrospectively analyzed.

RESULTS

The overall success rate was 96%. Rates for individual pathologies were 99% for CC, 92% for BA, and 96% for others. The success rate was 100% among children >3 years, but 92% when limited to infants. Post-ERCP hyperamylasemia and duodenal perforation occurred in 9% and 0.4% of cases, respectively. Regarding preoperative evaluation of the pancreaticobiliary system in CC, ERCP clearly delineated pancreaticobiliary maljunction (79%) and the pancreatic duct (94%), whereas it visualized the common bile duct and intrahepatic bile duct at relatively low rates (77% and 33%, respectively). ERCP successfully identified 16 cases (18%) with non-BA of 90 patients with suspected BA. Moreover, ERCP demonstrated only pancreatic duct in 70% of all BA.

CONCLUSIONS

ERCP among children including infants with CC and BA can be performed with fairly satisfactory results. Although pediatric ERCP can also help describe the pancreaticobiliary system in detail, its indication should be deliberately considered when anatomical information from less-invasive imaging modalities is insufficient.

Modifications in endoscopic practice for pediatric patients

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

The safety and efficacy of therapeutic ERCP in the pediatric population performed by adult gastroenterologists

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is much less commonly performed in the pediatric population compared to adults. As a result, few pediatric gastroenterologists receive adequate training in ERCP. At many institutions, pediatric ERCP is performed by adult gastroenterologists not formally trained in pediatric gastroenterology.

AIM

The purpose of this study was to assess the efficacy and safety of ERCP performed in pediatric patients by adult gastroenterologists in a single tertiary care center.

METHODS

We performed a retrospective analysis of pooled endoscopic procedures in pediatric patients (age<18 years) at the University of Maryland Medical Center, between 2003 and 2011, by two adult therapeutic endoscopists. Neither endoscopist had formal training in pediatric ERCP prior to 2003. Outcome measures included the procedure indications, cannulation success rates, procedure success rates, type of anesthesia, therapeutic interventions, frequency and type of procedure related complications, and technical complexity.

RESULTS

Forty-five patients were included with a mean age of 12 years (range 6-17). There were a total of 70 ERCP procedures. Choledocholithiasis was the most common indication. Modes of anesthesia included monitored anesthesia care (31, 44.3%), general anesthesia (22, 31.4%) and moderate conscious sedation (17, 24.3%). The papilla cannulation success rate was 98.6% (69/70). Therapeutic maneuvers included 31 biliary sphincterotomies, ten pancreatic sphincterotomies, 17 pancreatic duct stents, 16 bile duct stents, two cystgastrostomy stents, four biliary stricture dilations, one minor papillotomy site dilation, one mechanical lithotripsy and one ampullectomy. The procedural success rate was 97.1% (68/70). The overall complication rate was 7.1% (5/70) with a post-ERCP pancreatitis rate of 4.3% (3/70). Complications included infection (moderate-1), bleeding (moderate-1), and post-ERCP pancreatitis (mild-1, moderate-2).

CONCLUSIONS

ERCP procedures in pediatric patients can be safely and efficaciously performed by adult gastroenterologists trained in advanced endoscopy.

Endoscopic retrograde cholangiopancreatography in the pediatric population is safe and efficacious

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.

Comparison of performance and safety of endoscopic retrograde cholangiopancreatography across pediatric age groups

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.

ERCP with intracholedocal biopsy for the diagnosis of biliary tract rhabdomyosarcoma in children

Rhabdomyosarcoma is the most common tumor of the biliary tract in children. Although some features at preoperative radiographic studies (ultrasound, CT, MRI) may be suggestive of BT-RMS, until few years ago the final diagnosis was obtained by either operative or transcutaneous biopsy, thus exposing to a risk of regional dissemination. More recent and still anecdotal, is the histological diagnosis on tissue obtained by transluminal biopsy either during transhepatic cholangiography or endoscopic retrograde cholangio-pancreatography (ERCP), the latter having the major advantage of a much lower risk of loco-regional dissemination. We present two cases of BT-RMS that were histologically diagnosed by intracholedocal biopsy performed during ERCP, after being suspected at conventional imaging.

Laparoscopic common bile duct exploration in children is associated with decreased cost and length of stay: results of a two-center analysis

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.

Endoscopic retrograde cholangiopancreatography is safe and effective for the diagnosis and treatment of pancreaticobiliary disease following abdominal organ transplant in children

ERCP is a diagnostic and therapeutic imaging modality widely used in adult pancreaticobiliary disease, including the treatment of anastomotic strictures following liver and small bowel transplant. We have previously reported a large series of ERCP in children and demonstrated its safety and utility in pediatric disease. The aim of this study was to evaluate the safety of and indications for ERCP following abdominal organ transplant among pediatric patients by performing a subgroup analysis of our large cohort. Forty-eight ERCPs were performed on 25 children ages 62 days to 20 yr following isolated liver, isolated small bowel, or composite graft transplant. Mean time from transplantation at the time of ERCP was 18 months. The most common indication for ERCP was the evaluation of non-specific hepatobiliary complaints, including abdominal pain and elevated liver enzymes. ERCP was also commonly performed for the evaluation or treatment of known or suspected biliary tree strictures. Seventy-seven percent of cases included therapeutic intervention, including sphincterotomy in 40%, stent placement in 29%, and stone extraction in 19%. The overall complication rate among post-transplant patients was low (2.9%) and not significantly different than the complication rate reported in our previous study. A history of abdominal organ transplant was not associated with an increased risk of complication following ERCP (OR = 0.41, 95% CI = 0.05-3.33). In our experience, ERCP can be safely performed in children following liver, small bowel, and composite graft transplant with outcomes similar to those seen in a general pediatric population and may be especially useful for the diagnosis and treatment for biliary strictures following transplant. Further investigation of the relationship between the timing of ERCP relative to transplant and the safety of the procedure is needed.

Imaging findings in 75 pediatric patients with pancreaticobiliary maljunction: a retrospective case study

BACKGROUND

Pancreaticobiliary maljunction (PBM) is often associated with congenital choledochal cyst, protein plugs and pancreatitis. Early diagnosis and timely treatment largely depend on imaging. We assessed a series of PBM in children, comparing imaging procedure with histological and pathological findings with regard to diagnosis.

METHODS

A retrospective analysis was conducted in 75 pediatric patients with PBM. PBM was defined as common channel at >5 mm. Two radiologists assess the shape of the bile duct and gallbladder, pancreatitis, surgical pathology, symptom profiles, operative notes and pathological records were compared with the imaging findings.

RESULTS

Dilatation of the bile duct was detected in 45 subjects out of the 46 subjects who underwent computed tomography (CT) and nine was diagnosis as PBM. Forty out of 41 subjects were revealed bile duct dilatation in ultrasonography (US). Bile duct dilatation was seen in 59 out of 60 subjects receiving magnetic resonance cholangiopancreatography (MRCP) and 39 were diagnosed as PBM. Seventy-four out of 75 subjects successfully underwent intraoperative cholangiography (IOC); a diagnosis of PBM was established in 60 cases based on IOC alone. The diagnosis rate of pediatric PBM varied significantly among the four groups (P < 0.0001). Pair-wise comparison showed a significant difference between the groups of MRCP and CT (P < 0.0001), MRCP and US (P < 0.0001), IOC and CT (P < 0.0001), IOC and US (P < 0.0001), CT and US (P = 0.0027), and there is no significant difference between the groups of IOC and MRCP (P = 0.0502).

CONCLUSION

US, IOC, CT and MRCP are valuable in showing dilatation of the bile duct and complications in pediatric PBM. MRCP is non-invasive, gives clear views of the pancreaticobiliary junction and should be the first choice for the diagnosis of PBM in children.

Idiopathic small bowel diaphragm disease identified by laparoscopic-assisted double-balloon enteroscopy in a child: an integrated successful definitive therapeutic method

In adults, small bowel diaphragm disease is a rare complication of small bowel enteropathy secondary to the use of nonsteroidal antiinflammatory drugs. The main clinical manifestations are gastrointestinal bleeding and subacute obstruction, and management can be challenging. We present a case of a 5-year-old girl with small bowel diaphragm disease. To our knowledge, this is the first idiopathic case (no history of nonsteroidal antiinflammatory drug use) in the pediatric age group. This report describes an integrated successful definitive therapeutic method of double-balloon enteroscopy and minimal invasive bowel surgery for small bowel pathology.

Endoscopic retrograde cholangiopancreatography in neonatal cholestasis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is not as widely used in children as in adults and is performed in few specialized centers. The aim of the present study was to review the experience of ERCP in children younger than 3 months in a national referral center.

METHODS

A retrospective chart review was performed of all of the babies younger than 3 months who underwent ERCP between 2000 and 2010. Data on demographics, diagnosis, type of anesthesia, treatments, and complications were collected.

RESULTS

A total of 27 babies, 14 boys, were examined. Median age was 55 days (range 33-89). Ultrasound was normal in 16 infants, whereas others included small gallbladder (4), biliary stones (3), and dilated bile ducts (3). Thirteen infants underwent earlier liver biopsy, which was inconclusive. ERCP led to the diagnosis of biliary atresia in 13 infants who had subsequent surgery. In others, ERCP showed choledochal cyst (1), biliary stones (2), dilated bile ducts (1), and normal examination (6); there were 5 failures. The final diagnoses in our cohort were extrahepatic biliary atresia (15), biliary stones (5), neonatal hepatitis (4), choledochal cyst (1), paucity of intrahepatic bile duct (1), and congenital hepatic fibrosis (1). Diagnoses in the failed ERCP group included biliary atresia (2), bile duct paucity (1), and biliary stones (2). In 4 (19%) infants with clinical suspicion of extrahepatic biliary atresia, a normal ERCP ruled out the diagnosis and avoided an intraoperative cholangiogram. No complications, including pancreatitis, were reported.

CONCLUSIONS

ERCP in infants is feasible and has no complications. It may serve as an additional diagnostic tool in neonatal cholestasis in inconclusive cases and may prevent more invasive procedures. ERCP may be part of the algorithm of neonatal cholestasis when it is available and other investigations fail to confirm a diagnosis.

Bile duct anastomotic stricture after pediatric living donor liver transplantation

BACKGROUND/PURPOSE

Hepaticojejunostomy is a well-accepted method, whereas duct-to-duct anastomosis is gaining popularity for bile duct reconstruction in pediatric living donor liver transplantation (LDLT). Biliary complications, especially biliary anastomotic stricture (BAS), are not clearly defined. The aim of the present study is to determine the rate of BAS and its associated risk factors.

METHODS

The study included 78 pediatric patients (<18 years old) who underwent LDLT during the period from end of September 1993 to end of November 2010. The diagnosis of BAS was based on clinical, biochemical, histologic, and radiologic results.

RESULTS

All patients received left-side grafts. Thirteen patients (16.7%) developed BAS after LDLT. Among them, 3 patients (23.1%) had duct-to-duct anastomosis during LDLT. The median follow-up period for the BAS group and the non-BAS group was 57.8 and 79.5 months, respectively (P = .683). Ten of the patients with BAS required percutaneous transhepatic biliary drainage with or without dilatation for treating the stricture. Multivariable analysis showed that hepatic artery thrombosis and duct-to-duct anastomosis were 2 risk factors associated with BAS.

CONCLUSION

In pediatric LDLT, hepaticojejunostomy is the preferred method for bile duct reconstruction, but more large-scale research needs to be done to reconfirm this result.

[Cholelithiasis in infants, children and adolescents]

The prevalence of cholelithiasis is estimated within 0.13% and 2% of children under 19 years of age. Pigment stones are the commonest type of gallstones in children, without recognizable predisposing factors in infants or secondary to a predisposing disease such as chronic hemolysis and ileal disease in children. In adolescents, idiopathic cholesterol gallstones accounts for the majority, such as in adults. Gallbladder stones are found in 80 to 90% of cases and common bile duct stones in 10 to 20% of cases. When common bile duct stones are found, a choledocal cyst with anomalous pancreatobiliary duct junction needs to be excluded. Magnetic resonance cholangiopancreatography should be performed in first line. Cholecystectomy is not indicated for silent gallstones, except in children with a predisposing disease such as chronic hemolysis. Treatment of common bile duct stones includes interventional radiologic, endoscopic or surgical procedures. Stone extraction may be performed at endoscopic retrograde cholangiopancreatography with or without sphincterotomy, combined with laparoscopic cholecystectomy. In children without a predisposing disease or no residual gallstones indicating a cholescystectomy, conservative management (percutaneous cholangiography with biliary drainage) may be proposed in specialised centers, especially for infants. A hepaticojejunostomy is indicated in cases of choledocal cyst with anomalous pancreatobiliary duct junctions.

Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): a Norwegian prospective, multicenter study

OBJECTIVE

Novel imaging modalities have supplanted endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of hepatobiliary pancreatic diseases, but the use of ERCP as a diagnostic and therapeutic tool in current clinical practice is not well known. The main objective of this study was to describe and evaluate contemporary use of ERCP in Norway.

MATERIAL AND METHODS

Prospective and consecutive data were collected between January 2007 and December 2009 from voluntary institutional reports of ERCP activity at participating hospitals in the Gastronet database.

RESULTS

A total of 3840 procedures at 14 hospitals were registered during the study period. Data from 3809 procedures (53% females) were available for evaluation. Patients were ≥60 years of age in 2567 (67%) procedures. High co-morbidity (ASA score ≥3) was present in 32% of patients. The main indication for ERCP was evaluation and therapy of bile duct-related disorders. Successful bile duct cannulation was achieved in 93%. Pre-cut sphincterotomy was performed in 5% of procedures, and a guide wire to facilitate duct access was employed in 63%. Sphincterotomy, treatment for common bile duct stones (CBDS), and an insertion or change of bile duct stents were the most commonly employed procedures. Complications occurred in 10% of the patients, with a procedure-related mortality of 1%.

CONCLUSIONS

In Norway, ERCP is predominantly performed for CBDS and biliary strictures in elderly patients with associated co-morbidity. Patient selection, indications, and procedures are in concert with international guidelines and recommendations. Disease patterns in Norway differ slightly from those observed in central Europe and North America.

Choledochal cysts in infants and children: experiences over a 20-year period at a single institution

This analysis was undertaken to compare the clinicopathological features of infants with choledochal cysts to those of older children with these entities and to evaluate the surgical outcomes for both subject groups. The medical records of all children admitted to the Cathay General Hospital with choledochal cysts over a 20-year period were retrospectively reviewed. Twenty-five subjects were included and divided into the infant (<1 year at presentation; 8 subjects) and classical pediatric (1-18 years at presentation; 17 subjects) groups. Anatomical subtypes were: IA (16), IC (6), and IVA (3). The median biliary amylase value was markedly elevated for the pediatric group but not for the infant group. Most (82.4%) patients in the pediatric group, but none in the infant group, presented with abdominal pain. Jaundice and clay-colored stool were present in all patients in the infant group but only 35% of those in the pediatric group. All patients underwent choledochocystectomy and Roux-en-Y hepaticojejunostomy with good outcomes. Neonates/infants with choledochal cysts present differently from older children with these entities. Amylase measurements may serve to distinguish biliary atresia with cystic dilatation from choledochal cyst in neonates/infants. Prognosis following radical cyst excision and reconstruction with Roux-en-Y hepaticojejunostomy is excellent.

An appraisal of endoscopic retrograde cholangiopancreatography (ERCP) for pancreaticobiliary disease in children: our institutional experience in 231 cases

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool used by clinicians in the diagnosis and management of pancreaticobiliary disease. The safety and utility of ERCP for adults has been well documented. However, experience with ERCP for pediatric patients remains limited. This study aimed to examine the utility and safety of ERCP for diagnosis and therapy in pediatric surgical conditions.

METHODS

An institutional review board-approved retrospective chart review of all children younger than 21 years who underwent ERCP at a single children's hospital between 1992 and 2008 was performed. Age, sex, medical history, presenting symptoms, laboratory values, and discharge diagnoses were recorded. The ERCP findings, interventions performed, complications, and associated surgical procedures also were recorded.

RESULTS

A total of 231 ERCPs were performed for 167 children (98 girls and 69 boys) ages 62 days to 21 years. The mean patient age was 11.4 years, with 11% (n = 18) of the ERCPs performed for children younger than 2 years. Common indications for ERCP included chronic or recurrent pancreatitis (n = 106), acute pancreatitis (n = 42), and choledocholithiasis (n = 26). Additional indications included choledochal cyst (n = 2), congenital biliary obstruction (n = 2), and malignant biliary obstruction (n = 1). Therapeutic interventions were performed in 159 cases (69%) including sphincterotomy (n = 96), stone extraction (n = 55), and stent insertion (n = 52). Complications occurred for only 11 patients (4.76%), including 7 cases of post-ERCP pancreatitis. The use of ERCP for imaging resulted in surgical procedures in 58 cases.

CONCLUSION

Endoscopic retrograde cholangiopancreatography was used most commonly for children with pancreatitis and gallstone disease. It was used frequently for infants with a low complication rate. The majority of patients required therapeutic intervention, suggesting an important role for ERCP in the management of pancreaticobiliary disease in infants and children.