The role of ERCP in the diagnosis and treatment of idiopathic recurrent pancreatitis in children and adolescents

Therapeutic Endoscopic Retrograde Cholangiopancreatography for Pediatric Hepato-Pancreato-Biliary Diseases: A Systematic Review and Meta-Analysis

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].

Acute recurrent and chronic pancreatitis in children

Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step-up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non-opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner.

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.

Functional Pancreatic Sphincter Dysfunction in Children: Recommendations for Diagnosis and Management

OBJECTIVE

Functional pancreatic sphincter dysfunction (FPSD), previously characterized as pancreatic sphincter of Oddi dysfunction, is a rarely described cause of pancreatitis. Most studies are reported in adults with alcohol or smoking as confounders, which are uncommon risk factors in children. There are no tests to reliably diagnose FPSD in pediatrics and it is unclear to what degree this disorder contributes to childhood pancreatitis.

METHODS

We conducted a literature review of the diagnostic and treatment approaches for FPSD, including unique challenges applicable to pediatrics. We identified best practices in the management of children with suspected FPSD and formed a consensus expert opinion.

RESULTS

In children with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP), we recommend that other risk factors, specifically obstructive factors, be ruled out before considering FPSD as the underlying etiology. In children with ARP/CP, FPSD may be the etiology behind a persistently dilated pancreatic duct in the absence of an alternative obstructive process. Endoscopic retrograde cholangiopancreatography with sphincterotomy should be considered in a select group of children with ARP/CP when FPSD is highly suspected and other etiologies have been effectively ruled out. The family and patient should be thoroughly counseled regarding the risks and advantages of endoscopic intervention. Endoscopic retrograde cholangiopancreatography for suspected FPSD should be considered with caution in children with ARP/CP when pancreatic ductal dilatation is absent.

CONCLUSIONS

Our consensus expert guidelines provide a uniform approach to the diagnosis and treatment of pediatric FPSD. Further research is necessary to determine the full contribution of FPSD to pediatric pancreatitis.

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.

Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis

BACKGROUND

Chronic pancreatitis (CP) is a rare disease in childhood. Although ERCP is commonly performed in children, the effect of pancreatic duct stenting therapy in children with CP is unknown.

OBJECTIVE

To investigate the efficacy of pancreatic duct stenting in children with CP.

DESIGN

Retrospective analysis.

SETTING

National referral center.

PATIENTS

A total of 208 children with CP hospitalized between 1988 and 2012.

INTERVENTIONS

ERCP with pancreatic duct stenting.

MAIN OUTCOME MEASUREMENTS

Results of endoscopic therapy and number of pancreatitis episodes per year before and after treatment.

RESULTS

A total of 223 pancreatic duct stenting procedures were performed in 72 children. The median number of stent replacements was 3 (range 1-21). A statistically significant decrease in the number of pancreatitis episodes per year was observed: from 1.75 to 0.23 after endoscopic treatment (P < .05). Pancreatic duct stenting was performed more frequently in patients with hereditary pancreatitis (61.5%) and in children with CP and anatomic anomalies of the pancreatic duct (65%; P < .05).

LIMITATIONS

Retrospective analysis with the assessment of adverse events based on medical history.

CONCLUSION

Pancreatic duct stenting therapy is a safe and effective procedure in children with CP. This therapy should be recommended especially for children with hereditary pancreatitis and patients with anatomic anomalies of the pancreatic duct.

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.

Bildgebung

Ergibt sich aus dem pränatalen Ultraschallbefund oder durch klinische Hinweise der Verdacht auf eine Entwicklungsstörung des Darms des Neugeborenen, so ist die Situation am sichersten durch eine Röntgenaufnahme, und zwar des Thorax und Abdomens im Liegen oder im Hängen, zu klären.

A long-term follow-up study on endoscopic management of children and adolescents with chronic pancreatitis

OBJECTIVES

Data on therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for chronic pancreatitis (CP) in children and adolescents, especially with long-term follow-up of consequences, are rarely reported. The aim of this study was to determine the long-term follow-up results of therapeutic ERCP for CP in children and adolescents.

METHODS

All patients with CP who received therapeutic ERCP at Changhai Hospital from January 1997 to May 2009, with the age at first onset of pain being less than 18.0 years, were included. Attempts were made to contact all adolescents and follow-up data were recorded. Clinical data were assessed before and after every ERCP.

RESULTS

Follow-up information was available in 42 (91.3%) of the 46 patients who received therapeutic ERCP. There were 20 boys and 22 girls, with the age at first onset being 11.8+/-4.5 years. A total of 110 therapeutic ERCP sessions were performed in the 42 patients. The post-ERCP complication rate was 17.3%, including mild and moderate pancreatitis (n=17) and mild cholangitis (n=2). The mean follow-up period of time was 61.4 (range: 24-132) months. Five patients underwent subsequent surgery because of refractory abdominal pain after endotherapy. Of the remaining 37 patients who received therapeutic ERCP alone, abdominal pain improved in 30 (81.1%) patients, and was completely relieved in 24 (64.9%) patients during the period of follow-up.

CONCLUSIONS

Therapeutic ERCP may offer long-term improvement in pain in children and adolescents with CP.

Endoscopic retrograde cholangiopancreatography is useful and safe in children

PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) is a recognized diagnostic and therapeutic tool in the adult population. Its use in children has been more common in the last years. There are little data on safety and usefulness of that procedure in children. The aim of this study was to review the experience with ERCP in a tertiary university center dedicated to children.

METHOD

We conducted a retrospective chart review of patients seen at the Centre Hospitalier Universitaire Ste-Justine (Montreal, Quebec, Canada) who had undergone an ERCP between September 1990 and July 2007. Data on demographics, diagnosis, anesthesia type, treatments, and complications were collected.

RESULTS

Thirty-eight ERCPs were performed on 29 patients. There were 21 girls (72%), and median age at time of procedure was 10.3 years old (range, 3-17 years). Most had only one procedure performed. Two children had 2 interventions, and 1 child with papillary stenosis had 8 interventions linked to stent treatment. The ampulla was cannulated, and the procedure was successfully completed in 97% (37/38) of cases. General anesthesia and sedation were performed in 74% and 26% of procedures, respectively. Indications for ERCP were 29 recurrent or chronic pancreatitis (76%), 8 common bile duct obstructions (21%), and 1 choledochal cyst (3%). Endoscopic treatment was done in 29% of cases. The complication rate was 13.5%, and 4 clinical acute pancreatitis resolved with conservatory treatment. No severe pancreatitis, perforation, or bleeding was noted. Of the patients, 79% had their follow-up at the Centre Hospitalier Universitaire Ste-Justine for a median length of 43 months (range, 1-53 months).

CONCLUSION

Endoscopic retrograde cholangiopancreatography is used as a diagnostic and therapeutic procedure in children with a complication rate similar to that seen in adults. The need for general anesthesia is much more frequent with children. When performed by well-trained endoscopists, ERCP is useful and safe in children.

Post-ERCP pancreatitis in pediatric patients

OBJECTIVES

Pancreatitis is a known complication of endoscopic retrograde cholangiopancreatography (ERCP). Our aim was to assess the prevalence and severity of ERCP-associated pancreatitis using established criteria.

MATERIALS AND METHODS

Retrospective review of patients younger than 18 years undergoing ERCP complicated by post-ERCP pancreatitis defined by the 1991 consensus statement. Patients with chronic pancreatitis were studied separately using modified criteria. Risk factors for post-ERCP pancreatitis were analyzed.

RESULTS

Three hundred forty-three ERCPs were performed in 224 patients. Two hundred seventy-six ERCPs were performed in patients without chronic pancreatitis, 7 of which were complicated by post-ERCP pancreatitis (prevalence 2.5%). Patients undergoing diagnostic-only ERCP were less likely to develop post-ERCP pancreatitis (P<0.01). Sixty-seven procedures were performed on patients with chronic pancreatitis; 10 developed postprocedure pain requiring or prolonging hospitalization (prevalence 14.9%). Pancreatic duct stenting was a risk factor for post-ERCP pain in this subset of patients (P=0.02).

CONCLUSIONS

The prevalence of post-ERCP pancreatitis is low-2.5% excluding patients with chronic pancreatitis and 4.96% overall. Therapeutic procedures and the presence of chronic pancreatitis are risk factors for post-ERCP pancreatitis.

[Endoscopic retrograde cholangiopancreatography in patients aged less than 18 years old: our experience]

BACKGROUND

There is scant information on the use of endoscopic retrograde cholangiopancreatography (ERCP) in patients under 18.

OBJECTIVE

To analyze our experience in all patients under 18 who underwent ERCP.

PATIENTS AND METHODS

We performed a retrospective study of all ERCP conducted in patients under 18 between 1993 and 2006. We analyzed indications, endoscopic and radiologic findings, diagnostic and therapeutic success, and complications.

RESULTS

We included 31 patients who underwent 36 ERCP in total. The mean age was 9.89 +/- 5 years old. We used general anesthesia in 58.3% (21 patients), with a mean age of 8 +/- 5 years. The most frequent indications were complications after liver transplantation in 33.3% (12 patients), suspicion of biliary obstruction in 27.7% (10 patients), and pancreatitis in 22.2% (8 patients). We achieved cannulation and repletion in the selected duct in 94.4%. The most frequent pathologic findings were changes in the biliary tract after liver transplantation in 25% (9 patients). The results of ERCP were normal in 10 patients (27.7%). Therapeutic maneuvers were indicated in 17 out of the 34 (50%) examinations considered, achieving therapeutic success in 76.47% (13/17). Complications consisted of hemorrhage after simple sphincterotomy in one patient (2.8%) and mild pancreatitis in two patients (5.6%).

CONCLUSIONS

We found ERCP to be a safe procedure with a high diagnostic and therapeutic success rate, and a low rate of early complications.

[Endoscopic management of severe pancreatic and biliary diseases in children]

Endoscopic treatment of pancreatic pseudocysts and choledocal lithiasis is a first-line treatment in adults. Nevertheless, due to technical difficulties such a management is not always feasible in children. This series reports our results in the management of pancreatic and biliary diseases in children. Seven children, two months to 12 years old, underwent endoscopic management of pancreatic and biliary diseases. Two of them had choledocal lithiasis with jaundice or acute pancreatitis, two had pancreatic pseudocyst due to abdominal traumatism, two had chronic pancreatitis with a communicating pseudocyst in one case, and one had a biliary leakage after traumatism. All the endoscopic treatments were performed under general anesthesia. In six cases, the duodenoscope was a regular one with a large operating channel (Olympus TJF 160; Japan) employed for children aged 33 months to 12 years. In the case of the two months child, a "rendez-vous" technique was performed with a percutaneous approach of the common bile duct followed by an endoscopic sphincteroclasy using an axial endoscope allowing the extraction of a choledocal stone. In two cases, post-traumatic pancreatic pseudocysts (eight and 12 year-old children) were managed with the transgastric insertion of two double pig-tail stents. In two cases, children with chronic pancreatitis (38 months and 12 years old) were managed with pancreatic sphincterotomy. Biliary leakage in an 11-year-old child was managed with biliary sphincterotomy and stenting. All the children became symptom-free without any procedural complications with an 11 months median follow-up. Endoscopic treatment of pancreatic and biliary diseases is possible in children like in adults with the same procedures and results.

Biliary dyskinesia in the pediatric patient

The term biliary dyskinesia commonly describes a motility disorder of the biliary tract that is divided into two main categories: gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). SOD is further subdivided into biliary SOD and pancreatic SOD. GBD causes typical biliary colic without gallstones, whereas SOD typically presents with recurrent pancreatitis or chronic abdominal pain, usually after cholecystectomy. GBD and SOD are uncommon in children. Based on adult experience, this review discusses the diagnosis and treatment of GBD and SOD in the pediatric population.

Endoscopic ultrasonography in pediatric patients with gastrointestinal disorders

BACKGROUND

Endoscopic ultrasound is a diagnostic tool for evaluation of gastrointestinal diseases in adults, but in children the use of endoscopic ultrasound is limited. This study retrospectively evaluates endoscopic ultrasound indications in, safety in, and impact on children.

PATIENTS AND METHODS

We reviewed the data of all of the pediatric patients (<18 years old) that underwent endoscopic ultrasound in our institution. The main goal was to evaluate the impact of endoscopic ultrasound in this patient population. Significant impact was defined as a new diagnosis or treatment attributed to the endoscopic ultrasound examination.

RESULTS

Thirty-two children (21 boys, 11 girls) at mean age 12 +/- 5 years; (range = 1.5-18 years) underwent endoscopic ultrasound during a period of 6 years. The pancreas and biliary tract were examined in 19 children, esophagus in 8, and the stomach and rectum in 2 children each. Only 1 child had endoscopic ultrasound for duodenal indication. The indications in the pancreas and biliary tract group were recurrent pancreatitis in 9 children, cyst or mass in 6 children, and obstructive jaundice in 4 children. Indications in the esophagus group were stenosis in 4 children, and suspected duplication and esophageal mass in 2 children each. We used conscious sedation in 18 children and unconscious sedation in 12. Two children underwent endoscopic ultrasound with no anesthesia at all. In 7 cases, endoscopic ultrasound-guided fine-needle aspiration was performed. The procedure was successful in all of the patients with no complications. Endoscopic ultrasound changed the diagnosis or therapy in 14 cases.

CONCLUSIONS

Endoscopic ultrasound is an effective tool in the evaluation of pediatric gastrointestinal patients, mostly with pancreatobiliary or esophageal disorders. Endoscopic ultrasound is a safe procedure with a significant impact in almost half of the children examined.

Diagnostic and therapeutic ERCP in the pediatric age group

The role and value of endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric age group is not well established, because pancreatic and biliary diseases are less common in children. This however is not the case in areas like the Eastern Province of Saudi Arabia where sickle cell disease (SCD) and other hemoglobinopathies are common, with increased frequency of cholelithiasis and choledocholithiasis. The purpose of this study was to evaluate the indications, findings, safety and therapies of ERCP in children. One hundred and twenty five children had diagnostic and/or therapeutic ERCP as part of their management at our hospital. Their medical records were reviewed for: age at diagnosis, sex, Hb electrophoresis, indication for ERCP, findings, therapy and complications. There were 77 males and 48 females. Their age at presentation ranged from 5-18 year (mean 13.25 year). The majority of them had sickle cell disease (77.6%). The indications for ERCP were: obstructive jaundice (67.2%), recurrent biliary colic with or without jaundice (10.4%), acute and chronic pancreatitis (7.2%), postoperative bile leak (2.4%), cholangitis with obstructive jaundice (2.4%), hepatitis of unknown etiology (3.2%), cirrhosis of unknown etiology (4%), thalassemia with jaundice (0.8%), hemobilia (0.8%), acute cholecystitis with jaundice (0.8%), and sickle cell disease with ulcerative colitis and obstructive jaundice (0.8%). In six children, ERCP was done following laparoscopic cholecystectomy. ERCP was carried out under sedation in 91 (72.8%) children and under general anesthesia in 34. It was successful in 121 (96.8%) children while cannulation of the Ampulla failed in four. ERCP was normal in 43 children, but eight of them showed evidence of recent stone passage and in six, there were gallstones. In the remaining children, ERCP revealed: normal CBD with stones (18 patients), dilated CBD with stones (17 patients), dilated CBD without stones (19 patients), dilated biliary tree with stones (10 patients), dilated biliary tree without stones (six patients), bile leak (two patients), dilated biliary tree with stones and choledocho-duodenal fistula (one patient), choledochal cyst (two patients), septate gallbladder (one patient), normal ERCP with multiple pancreatic cysts (one patient) and biliary stricture (one patient). The following procedures were carried out: 35 had endoscopic sphincterotomy and stone extraction, 20 had endoscopic sphincterotomy, four had CBD stenting, one underwent removal of a stent, two had insertion of a nasobiliary tube and one had biliary endoprosethesis. There was no mortality. One had bleeding from the site of sphincterotomy which stopped after adrenaline injection. Four patients (3.2%) developed transient mild pancreatitis which settled conservatively. ERCP in the pediatric age group is safe both as a diagnostic and therapeutic procedure. ERCP can provide valuable information which aid in the diagnosis of biliary and pancreatic diseases in children as well as therapy with the technical feasibility of endoscopic sphincterotomy. This is specially so in the era of laparoscopic cholecystectomy, where ERCP should be the treatment of choice in children with CBD stones who are going or have previously undergone laparoscopic cholecystectomy.

Endoscopic management of sphincter of Oddi dysfunction in children

BACKGROUND

Data on sphincter of Oddi dysfunction (SOD) in children are scant. Most children diagnosed with SOD are treated by biliary sphincterotomy with suboptimal results. The efficacy and safety of pancreatic and dual sphincterotomy in children with SOD has not been previously reported.

OBJECTIVE

To evaluate the efficacy and safety of pancreatic and dual sphincterotomy in children with SOD.

MATERIALS AND METHODS

Prospective evaluation of all children who underwent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincter of Oddi manometry for evaluation of suspected SOD over a 3-year period. Children diagnosed with SOD underwent pancreatic or dual sphincterotomy with prophylactic pancreatic stenting.

RESULTS

SOD was diagnosed by sphincter of Oddi manometry in 6 of 11 children who underwent ERCP for suspected SOD. Of the 6 children (mean age, 11 years; range, 5-16; 4 girls) with SOD, 3 presented with recurrent pancreatitis and 3 with postcholecystectomy pain. Pancreatic sphincter hypertension was noted in all 6 patients; concomitant biliary sphincter hypertension was noted in 3 patients with postcholecystectomy pain. Patients with recurrent pancreatitis underwent pancreatic sphincterotomy and those with postcholecystectomy pain underwent dual sphincterotomy. Prophylactic pancreatic stents were placed in all patients. One girl experienced mild post-ERCP pancreatitis. At a mean follow-up of 583 days (range, 325-1445), 4 patients were asymptomatic, 1 experienced partial symptom relief and 1 had recurrent symptoms.

CONCLUSIONS

As in adults, pancreatic and dual sphincterotomy, in expert hands, is effective and safe in a subgroup of children with SOD. Prospective, randomized trials with larger number of patients are required to validate the efficacy of endotherapy in children with SOD.

Sphincter of Oddi dysfunction in children

Sphincter of Oddi dysfunction (SOD) is a clinical entity caused by a primary motility alteration of either the biliary or the pancreatic sphincter. SOD is a rare condition that has been scarcely reported in children. Most of the reported literature has been in children with idiopathic recurrent pancreatitis. These children are treated endoscopically by dual sphincterotomy of the pancreatic and common duct sphincters. However, the safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further study.

Endoscopie interventionnelle dans les pancréatites de l'enfant

Authors report on 3 cases of children treated by therapeutic endoscopic retrograde cholangiopancreatography for pancreatitis (ERCP). The first child presented with familial pancreatitis: he was treated by sphincterotomy and lithiasis extraction. The second child presented with pancreatitis secondary to pancreas divisum: she was treated by sphincterotomy and stunt of small caroncula. The third child presented with severe pancreatitis with pseudocyst: after drainage she was treated by sphincterotomy, Wirsung dilatation and lithiasis extraction. ERCP is a beneficial treatment and may be alternative to surgery in complicated pancreatitis.

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography in children: a large series report

OBJECTIVES

Our goal is to evaluate the indications, findings, therapies, safety, and technical success of endoscopic retrograde cholangiopancreatography (ERCP) in children.

METHODS

Our database was searched for patients 17 years of age or younger undergoing ERCP between January 1994 and March 2003. Additional information was obtained by chart review. The safety and technical success of ERCP were examined. Complications were classified by the consensus criteria.

RESULTS

A total of 245 patients (95 M, 150 F; mean age 12.3 years) underwent 329 examinations. Indications included biliary pathology (n = 93), pancreatic pathology (n = 111), and chronic abdominal pain of suspected biliary or pancreatic origin (n = 41). The ERCP findings were bile duct stone(s) (n = 29), benign biliary stricture (n = 19), primary sclerosing cholangitis (n = 7), anomalous pancreaticobiliary union (n = 8), choledochal cyst (n = 5), bile duct leak (n = 6), malignant biliary stricture (n = 2), biliary atresia (n = 1), chronic pancreatitis (n = 44), pancreas divisum (n = 26), pancreatic duct stricture with (n = 6) or without (n = 9) leak, pancreatic tumor (n = 1), periampullary adenoma (n = 2), and sphincter of Oddi dysfunction (n = 65). Endoscopic therapies were performed in 71% of the procedures and included sphincterotomy, stone extraction, stricture dilation, endoprosthesis placement, snare papillectomy, and cystoduodenostomy. Thirty-two (9.7%) post-ERCP complications occurred and included cholangitis in 1 patient and pancreatitis in 31. The pancreatitis was graded mild in 24, moderate in 5, and severe in 2. No mortality related to ERCP occurred.

CONCLUSIONS

Diagnostic and therapeutic ERCP results are similar in children and adults except for a lower incidence of malignant disease in children. Technical success rates are high. However, ERCP-related pancreatitis is not uncommon, and the risk and benefits should be carefully reviewed before proceeding. Outcome data are necessary and is currently being accumulated at our institution.

Impact of EUS in the evaluation of pancreaticobiliary disorders in children

BACKGROUND

While the role of EUS in the evaluation of pancreaticobiliary (PB) disorders in adults is well established, its utility in children remains unproven. This prospective study evaluates the feasibility, the safety, and the impact of EUS in the evaluation of PB disorders in children.

METHODS

All children (<18 years) referred for ERCP for evaluation of suspected PB disorders who underwent EUS before scheduled ERCP. The main outcome measure was to evaluate the impact of EUS in the evaluation of PB disorders in children. EUS was considered to have a significant impact if a new diagnosis was established or if the findings altered subsequent management.

RESULTS

Fourteen patients (mean age 13 years; range 5-17 years) underwent 15 EUS procedures over a 3-year period. Main indications were the following: acute or recurrent pancreatitis (6 patients), suspected biliary obstruction (5), and abdominal pain suggestive of PB origin (3). EUS diagnosed chronic pancreatitis (3 patients), idiopathic fibrosing pancreatitis (2), carcinoid tumor (1), pancreatic pseudocyst (1), pancreas divisum (1), choledocholithiasis (1), duodenal duplication cyst (1), and normal (4). Diagnosis of idiopathic fibrosing pancreatitis and carcinoid tumor was established by EUS-guided FNA. The procedure was successful in all patients, and no complications were encountered. EUS had an impact on patient management in 93% of cases: established new diagnosis (10), precluded need for ERCP (9), and provided additional information that facilitated focused endotherapy (4). A limitation was the small number of enrolled patients and absence of long-term clinical follow-up.

CONCLUSIONS

EUS and EUS-guided FNA are feasible, safe, and have significant impact that alters subsequent management in the majority of children with PB disorders. Further studies and dissemination of information is required to facilitate its increased application in children.

[Imaging of the pediatric pancreas: state of the art]

The use of high frequency (7-12 MHz) transducers on state of the art US units equipped with Doppler imaging provides excellent evaluation of the pediatric pancreas that compares to other cross-sectional imaging techniques. The availability of multidetector CT imaging reduces the need for sedation but requires additional review of the indications and protocols to avoid unnecessary radiation exposure. Evaluation of pancreatitis and tumors remains the main indication. Advances in MR imaging and MRCP has lead to very good results in children. Storage diseases of the pancreas can be diagnosed at MRI. The length of the examinations, the need for sedation and the limited spatial resolution remain the main pitfalls of MR imaging of the pancreas in pediatric patients.

Technical outcomes and complications of ERCP in children

BACKGROUND

The aim of this study was to compare the success and complications of diagnostic and therapeutic ERCP in children (age <18 years) and adult patients.

METHODS

A retrospective case-controlled study was conducted in which all children undergoing ERCP at two centers (1994-2002) were identified from endoscopy databases and were matched with adult patients for all variables (e.g., indication, procedure complexity) except age. Outcomes with regard to technical success and complications were compared between the adult and the pediatric cohorts. Grade of procedure complexity and procedure-related complications were defined by using established criteria.

RESULTS

A total of 116 children (mean age 9.3 years, range 1 month to 17 years; median age 8.1 years) and 116 matched adult patients (mean age 56.3 years, range 20-83 years; median age 49.7 years) underwent 163 and 173 ERCP procedures, respectively. According to procedure complexity grade, each group included the same number of patients, grade I, 72 patients; grade II, 12 patients; and grade III, 32 patients. Procedure success rate was 97.5% in children vs. 98% in the adult cohort (p= not significant). The complication rate was not significantly different between children and adult patients (3.4% vs. 2.5%). Most complications were of mild severity and encountered only in patients who underwent grade III procedures, with the exception of a single adult in whom moderate post-sphincterotomy bleeding developed after extraction of a large bile duct stone (grade II complexity).

CONCLUSIONS

When ERCP is performed in children by expert endoscopists, the success rate is high and the complication rate is low, both being comparable with those for ERCP in adult patients.

Pancreas divisum: an uncommon cause of acute pancreatitis

Pancreas divisum is the most common congenital anomaly of the pancreas and has been reported to be an infrequent cause of acute and recurrent pancreatitis. The authors herein report a 4-year-old child with acute pancreatitis associated with pancreas divisum. Coexistent ascariasis initially suggested a diagnosis of pancreatic ascariasis.

Management of childhood pancreatic disorders: a multidisciplinary approach

INTRODUCTION

Data on therapeutic endoscopy and radiologic interventions for the management of childhood pancreatic disorders are relatively limited. This study focuses on the multidisciplinary approach to the management of pancreatitis in children.

PATIENTS AND METHODS

Children with pancreatic disorders were studied from January 1992 to May 2001. Acute pancreatitis (AP) was diagnosed by clinical evaluation, serum amylase more than three times normal, and morphologic abnormalities of the pancreas on imaging. Children with recurrent abdominal pain, pancreatic calcification or ductal stones on imaging, and pancreatic ductal changes on endoscopic retrograde cholangiopancreatography (ERCP) were diagnosed with chronic pancreatitis (CP). Patients were treated by gastroenterologists, surgeons, and interventional radiologists. Pancreatic exocrine insufficiency was diagnosed in appropriate settings.

RESULTS

Fifteen children--6 with AP (posttrauma, 3; gallstone disease, 1; and viral, 1), 7 with CP, and 2 with pancreatic exocrine insufficiency--were diagnosed. Local complications observed in children with AP included pseudocyst in three, and infected acute fluid collection, right-sided pleural effusion, and ascites in one patient each. Complications of AP were managed with percutaneous catheter drainage (n = 3; pseudocyst, 2; infected fluid collection, 1), additional pancreatic duct stenting (n = 2), surgical drainage (n = 1), and octreotide for pleural effusion (n = 1). Signs of CP included abdominal pain (n = 7), obstructive jaundice resulting from lower common bile duct stricture (n = 2), and bleeding from gastroduodenal artery pseudoaneurysm (n = 1). Pancreatic duct stenting relieved pain in one patient, and steel coil embolization arrested bleeding from the pseudoaneurysm. Common bile duct strictures were managed by surgical bypass (n = 2), one of which required preoperative endoscopic bile duct stenting for management of cholangitis. Two other patients with CP required no intervention.

CONCLUSION

A multidisciplinary approach of radiologic and endoscopic interventions and surgery are complimentary to each other in achieving successful outcomes of complicated childhood pancreatitis.

Endoscopic retrograde cholangiopancreatography in children and adolescents

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) is becoming a more frequently used diagnostic and therapeutic tool in children. We sought to determine the indications, feasibility, safety, and effect on patient management of ERCP in pediatric patients of varying age.

METHODS

All ERCPs performed during a 4-year period in patients aged 18 years or less at an academic hospital were retrospectively reviewed. The indications, type of anesthesia administered, type of duodenoscope used, diagnostic findings, therapeutic interventions, complication rate, and effect on management were compared between children (age 0-12 years) and adolescents (age 13-18 years).

RESULTS

A total of 53 procedures were performed in 43 patients whose median age was 13.5 years. ERCP was successful in 50 of 53 cases (94%) with a complication rate of 6%. Endoscopic therapy was provided in 24 of 53 cases (45%). Compared with adolescents (n = 28), children (n = 25) were more likely to receive general anesthesia (96% vs. 29%; P < 0.001) and undergo ERCP with a pediatric duodenoscope (0% vs. 40%). ERCP affected management in 73% of cases, equally in both groups.

CONCLUSION

ERCP is a successful and safe diagnostic and therapeutic modality in a variety of pancreatobiliary disorders that directly affects management in children of all ages.

Endoscopic retrograde cholangiopancreatography in the management of pancreaticobiliary disorders in children

BACKGROUND AND AIM

The role of endoscopic retrograde cholangiopancreatography (ERCP) is not yet fully established in children. The purpose of this study was to assess the use of ERCP in the diagnosis and management of various pancreaticobiliary disorders in children.

METHODS

Eighty-four ERCPs were performed over 5.5 years in 72 children with suspected pancreaticobiliary tract disorders with an adult-type duodenoscope. In all cases, indications, procedure time, ERCP findings, complications, patients course and therapeutic intervention (if any) were recorded.

RESULTS

The mean (+/- SD) age of these children was 8.8 +/- 3.3 years. Successful cannulation was possible in 70 (97%) cases. Of the 44 cases with suspected biliary tract disease, 14 had a choledochal cyst, 13 had portal biliopathy, two each had CBD stones, primary sclerosing cholangitis and a bile leak, one had biliary ascariasis, eight had a normal cholangiogram, and CBD cannulation failed in two. Eight of the 28 children with suspected pancreatic disorders had chronic pancreatitis, five had pancreatic duct disruption, three had pancreas divisum and the rest had a normal pancreatogram (including all eight children with unexplained abdominal pain). Therapeutic ERCP was performed in 22 children, endoscopic nasobiliary or a nasocystic drain was placed in 16, biliary stenting was conducted in two, pancreatic duct stenting was conducted in three, and minor papilla dilation was conducted in one child. Six children had mild procedure-related complications.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is very useful in the treatment of cholangitis, bile leak, pseudocyst and pancreatic fistulae in children. However, its role in unexplained abdominal pain is doubtful.

Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept

BACKGROUND

The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition.

METHODS

We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians.

RESULTS

An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis.

CONCLUSIONS

Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.

ERCP in the management of pediatric pancreatitis

BACKGROUND

Although ERCP is commonly performed in children, the effect of findings at ERCP on the subsequent management of pediatric pancreatitis is unknown.

METHODS

We retrospectively reviewed charts to determine the impact of ERCP on the management of recurrent acute or chronic pancreatitis in 17 consecutive children (3 boys and 14 girls, 3 to 16 years, mean 11.2 years) with recurrent acute (n = 13) or chronic pancreatitis (n = 4) who underwent ERCP. Radiographs were reviewed in a blinded manner, and the effect of ERCP findings on subsequent management was determined.

RESULTS

In 16 of 17 patients (94%), the pancreatic duct was successfully visualized. Of the 16 studies, 9 (56%) had abnormal findings. A change in therapy occurred in all 9 patients as a result of the findings at ERCP. Of the 7 patients with a prior abnormal CT or ultrasound, 5 (71%) had an abnormal ERCP, all resulting in a change in therapy. Three of the 9 patients (33%) without radiographic abnormalities had an abnormal ERCP that, in each case, resulted in a change in therapy. Overall, findings at ERCP altered therapy in 52% of pediatric patients studied with recurrent acute or chronic pancreatitis. A prior abnormal CT had a high predictive value with respect to ERCP resulting in a change in management (83%).

CONCLUSIONS

ERCP is useful in the management of pediatric recurrent acute or chronic pancreatitis; abnormalities are found at a rate similar to those found in adults.

Endoscopic retrograde cholangiopancreatography in paediatric patients with biliary disorders

Endoscopic retrograde cholangiopancreatography (ERCP) has long been used in children. The usefulness of ERCP in paediatric patients with various biliary disorders, however, has not been well documented. Thirty-two sessions of ERCP performed in 29 paediatric patients ranging in age from 1 month to 15 years were evaluated. Endoscopic retrograde cholangiopancreatography was to confirm diagnosis or to obtain detailed information about their pancreaticobiliary system. Cannulation was successful in all patients. Opacification of the biliary tracts was also successful in all except for three patients with extrahepatic biliary atresia. Endoscopic retrograde cholangiopancreatography was assessed to be successful in making a differential diagnosis of neonatal hepatitis from extrahepatic biliary atresia, and in having a confirmed diagnosis of anomalous arrangement of the pancreaticobiliary ductal system associated with choledochal cyst. The procedure was also useful for obtaining detailed information on the pancreaticobiliary system in the other children. No accidents occurred during the endoscopic procedures in any of the paediatric patients. When a confirmed diagnosis or detailed information is needed in paediatric patients with biliary disorders, ERCP is a useful and safe technique.

Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders

A multidisciplinary approach using traditional open surgery, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery has revolutionized the care of the adult with pancreaticobiliary disease. This study focuses on a similar collaborative effort to diagnose and treat children with pancreaticobiliary disorders. Charts of all patients treated on the pediatric surgery service between June 1990 and May 1995, who also underwent ERCP, were abstracted for disease process, presenting symptoms, laboratory evaluation, surgical or endoscopic procedures, and eventual outcome. Twenty-six children were identified, ranging from 6 months to 19 years of age. Pancreaticobiliary disorders included pancreas divisum (n = 1), choledochal cyst (n = 4), pancreaticobiliary trauma (n = 4), cholelithiasis and choledocholithiasis (n = 17). The pancreaticobiliary tree was successfully visualized by ERCP in 25 of 26 (96%) patients. Fifteen of these patients also underwent attempted therapeutic endoscopic procedures, with 13 (87%) performed successfully. Three patients with choledochal cyst had stents placed preoperatively for cholangitis, all of whom have undergone successful choledochal cyst excision. Two trauma patients underwent attempted stenting of a bile leak and bile duct stricture, respectively, both of which were unsuccessful, necessitating surgical correction. Seventeen patients with cholelithiasis underwent ERCP to rule out choledocholithiasis. Ten patients were found to have common duct stones, and all stones were endoscopically extracted, including those in a 6-month-old child. Overall survival rate was 96% (25 of 26), with the one death occurring in a trauma patient unrelated to his pancreaticobiliary disorder. A multidisciplinary approach using traditional open surgery, ERCP and laparoscopic surgery can successfully treat even young children with pancreaticobiliary disorders. In experienced hands, diagnostic ERCP and therapeutic endoscopic intervention can be performed successfully in most pediatric patients, greatly simplifying the surgical management of these potentially complex problems.

Pancreatitis in children--experience with 43 cases

Pancreatitis in children is not common and can be associated with severe morbidity and mortality. We encountered 43 children, ranging in age from 2 to 18 years, with pancreatitis over the past 10 years. The diagnosis of pancreatitis was made in those patients who showed: (1) significant intra-operative pathology or; (2) clinical findings of pancreatic inflammation and laboratory confirmation. More than one third (16 cases) of the cases were due to trauma, other causes included systemic disease (10), structural disease (8), and toxins or drugs (4). Five cases were classified as idiopathic. Most of the patients presented with abdominal pain (95%) and vomiting (56%). Jaundice was found in 7 patients and an abdominal mass in 2. Morbidity included pseudocyst (10), relapse (4), hyperglycaemia (4) and miscellaneous problems. Eight (50%) of the patients with trauma and 6 (86%) of the patients with structural diseases required surgery. Other patients were managed conservatively with bowel rest, gastric decompression, intravenous fluid and total parenteral nutrition. One case had a fatal outcome. All the survivors did well in long term follow up. Relevant literature has been reviewed and the sensitivity of various diagnostic modalities compared and discussed. A lesser known association between pancreatitis and structural anomalies such as choledochal cyst is discussed. To our knowledge, the present review is the first on pancreatitis in Chinese children.

CONCLUSION

Pancreatitis can occur from a wide variety of causes and may result in severe complications. Early diagnosis, close monitoring and aggressive intervention are mandatory to reduce morbidity and mortality.