ERCP in infants, children and adolescents is feasible and safe: results from a tertiary care center

Analysis of the efficacy and safety of endoscopic retrograde cholangiopancreatography for the treatment of pediatric pancreatobiliary diseases

BACKGROUND

Traditional surgical procedures are highly invasive and risky for children with pancreatic and biliary diseases. Endoscopic retrograde cholangiopancreatography (ERCP) has been used mostly in adults because it is a safe and effective surgical procedure. Its application in children will contribute to the treatment and prognosis of children with pancreatic and biliary diseases.

AIM

To analyze the efficacy and safety of ERCP for the treatment of pediatric pancreatobiliary diseases.

METHODS

A retrospective study was performed using the medical records of 101 pediatric patients who received treatment for pancreatobiliary diseases at Children's Hospital Capital Institute of Pediatrics from April 2022 to April 2024. The patients were divided into an observation group (n = 52, treated with ERCP) and a control group (n = 49, treated with traditional surgical methods). Diagnostic and therapeutic outcomes of ERCP were statistically analyzed. Treatment efficacy, time to resume eating, and hospital stay duration were compared between the two groups. Indicators of liver function were monitored preoperatively and one week postoperatively. Dynamic changes in C-reactive protein (CRP) and serum amylase levels were assessed preoperatively and at 6 and 24 hours postoperatively. Postoperative complications were also compared. Logistic multivariate regression was used to analyze the independent effect of ERCP on outcomes.

RESULTS

For the observation group, 36 and 16 patients were diagnosed with biliary and pancreatic diseases, respectively. Compared with the control group, the observation group exhibited a higher overall effective rate (P < 0.05), shorter times to resume eating, shorter hospital stays (P < 0.05), and significantly improved postoperative liver function (P < 0.05). CRP and serum amylase levels were significantly increased in both groups at 6 and 24 hours postoperatively (P < 0.05), but were significantly lower in the observation group (P < 0.05). The observation group also had a lower incidence of complications (P < 0.05). ERCP was an independent factor affecting treatment efficacy, length of hospital stay, total bilirubin, aspartate aminotransferase, and alanine aminotransferase, CRP, serum amylase, and the occurrence of complications in children with pancreaticobiliary diseases (P < 0.05).

CONCLUSION

ERCP effectively enhances the treatment efficacy of pediatric pancreatobiliary diseases, with a reduced inflammatory response, faster postoperative recovery, and fewer complications. ERCP is a safe and effective diagnostic and therapeutic method for pediatric pancreatobiliary diseases.

ERCP-Related adverse events in pediatric patients: a 10-years single-site review

PURPOSE

This retrospective analysis aimed to assess the feasibility and safety of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients by examining ERCP-related adverse events (AEs) occurring over a decade at a single center.

METHODS

Pediatric patients under 18 years old who underwent ERCP at the Second Hospital of Hebei Medical University from 1/2013 to 11/2023 were included. ERCP-related AEs were defined according to ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Clinical data of patients experiencing ERCP-related AEs were obtained from electronic medical records for analysis.

RESULTS

Over the past decade, a total of 76 pediatric patients underwent 113 ERCP procedures, including 26 patients who underwent repeat ERCP, totaling 63 procedures. There were 32 males and 44 females, with a median age of 13 years (range 3 years and 5 months-17 years and 9 months). Among all ERCP procedures, 14 (12.4%) were diagnostic and 99 (87.6%) were therapeutic, with a 100% success rate. 16 cases (14.2%) of ERCP-related AEs, all post-ERCP pancreatitis (PEP), were observed, while no other AEs defined by ESGE such as bleeding, perforation, cholangitis, cholecystitis, or sedation-related events were noted. Additionally, 23 cases (20.4%) of ERCP-related AEs not included in the ESGE definition were observed, including post-ERCP abdominal pain in 20 cases (17.7%), post-ERCP nausea and vomiting in 2 cases (1.8%), and unplanned reoperation in 1 case (0.9%). In the 26 cases of pediatric patients who underwent repeat ERCP, we observed that AEs occurred in 15 cases (57.7%) during their initial ERCP, which was much higher than the overall average level.

CONCLUSIONS

Post-ERCP abdominal pain and PEP are the most common ERCP-related AEs in pediatric patients, while severe AEs such as bleeding and perforation are rare. The incidence of AEs after initial ERCP in pediatric patients who received repeat ERCP is higher than the overall average level. Based on our center's experience, we believe that ERCP can be safely performed in children over 3 years old with biliary and pancreatic diseases and obtain reliable clinical benefits. However, active monitoring and management of ERCP-related AEs are essential to improve the clinical outcomes of pediatric ERCP.

A therapeutic ERCP in an only 5.9 kg infant with obstruction jaundice using JF-260V duodenoscope

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has found extensive use in pediatric patients; however, challenges persist in the application of therapeutic ERCP in infants.

CASE PRESENTATION

This case report details the presentation of a 5.9-kilogram infant with obstructive jaundice and suspected hemolytic anemia who underwent ERCP to alleviate biliary obstruction. The infant was admitted due to clay-colored stools, jaundice, and liver injury. Ultrasound and magnetic resonance cholangiopancreatography (MRCP) revealed dilation of the common bile duct (CBD) accompanied by the presence of stones. ERCP was conducted using a JF-260V duodenoscope under general anesthesia. Successful stone extraction and biliary drainage were achieved.

CONCLUSIONS

In centers with considerable expertise in ERCP and pediatric anesthesia, the use of a conventional adult duodenoscope for therapeutic ERCP in infants can be considered safe and feasible, provided careful and stringent patient selection criteria are applied. In the future, clear guidelines and standardized protocols for the indications and procedures of pediatric ERCP should be established.

Endoscopic Retrograde Cholangiopancreatography on Pediatric Patients: Experience of a Portuguese Adult Gastroenterology Department

Introduction

Experience with endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population is limited. Few medical centers have experts specifically trained in pediatric therapeutic endoscopy. As a result, patients are generally referred to adult endoscopists with high experience in the procedure. The aim of this study was to characterize the experience of an adult endoscopy unit with ERCP on pediatric patients, with a special focus on very young patients.

Methods

We retrospectively analyzed indications, technical success rate, final clinical diagnosis, and complications of ERCPs in children <18 years at our tertiary referral hospital center between January 1994 and June 2022.

Results

Sixty-five ERCPs were performed on 57 children with a median age of 13 years (range 1-17 years). Eleven ERCPs were performed on 9 patients up to 5 years old. Indications for ERCP were as follows: biliary obstruction (n = 40), mainly due to choledocholithiasis, lithiasic acute pancreatitis (n = 19), recurrent pancreatitis (n = 3), stent extraction (n = 2), and post-operative biliary fistula (n = 1). The cannulation success rate was 95.1%. Therapeutic interventions were performed in 79% of ERCP. All patients were followed up as inpatients. Complications were recorded in two procedures (3.1%), and no procedure-related mortality occurred.

Conclusion

In our experience, ERCP in children can be safely performed with high success rates by advanced adult-trained expert endoscopists at a high-volume center.

Surgical and Endoscopic Intervention for Chronic Pancreatitis in Children: The Kings College Hospital Experience

Paediatric chronic pancreatitis (CP) is a rare and debilitating pathology that often requires invasive diagnostics and therapeutic interventions either to address a primary cause such as a pancreaticobiliary malunion or to deal with secondary complications such as chronic pain. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are two endoscopic modalities that have an established diagnostic role in paediatric CP, and their therapeutic utilisation is increasing in popularity. Surgical decompression of the obstructed and dilated pancreatic duct plays a role in alleviating pancreatic duct hypertension, a common association in CP. Surgery equally has a role in certain anatomical abnormalities of the pancreaticobiliary draining system, or occasionally in some CP complications such as drainage of a symptomatic pancreatic pseudocyst.

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.

Endoscopic retrograde cholangiopancreatography for diagnosing and treating pediatric biliary and pancreatic diseases

BACKGROUND

This study evaluated the safety and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients with biliary and pancreatic diseases. A retrospective analysis was conducted on 57 ERCP procedures performed in 41 children, primarily for treating pancreatic diseases. The overall success rate was 91.2%, with no major complications observed. Post-ERCP pancreatitis (PEP) occurred in 8.8% of cases. Follow-up examinations over one year showed no recurrence of biliary or pancreatic diseases. Notably, endoscopic treatment led to a significant increase in body mass index (BMI). These findings demonstrate the valuable role of ERCP in managing such conditions.

AIM

To evaluate the safety and efficacy of ERCP for the management of biliary and pancreatic diseases in pediatric patients.

METHODS

We conducted a retrospective analysis of data from children aged 1-18 years who underwent ERCP for biliary and pancreatic diseases at Beijing Children's Hospital between January 2021 and December 2022. The collected data included procedure time, endoscopic treatment, success rate, and postoperative complications.

RESULTS

Forty-one children underwent 57 ERCP procedures, including 14 with biliary duct disease and 27 with pancreatic disease. The mean age of the patients was 7.48 ± 3.48 years. Biliary duct-related treatments were performed 18 times, and pancreatic disease treatments were performed 39 times. ERCP was primarily used to treat pediatric pancreatic diseases [68.4% (39/57) of the procedures]. The overall success rate was 91.2% (52/57 patients). PEP was noted in five patients (8.8%, 5/57), and no instances of bleeding, perforation, or cholangitis were observed. The patients were followed up for over one year, and no recurrence of biliary or pancreatic diseases was detected. Importantly, BMI significantly increased after endoscopic treatment compared to that before treatment (P = 0.001).

CONCLUSION

The high success rate and lack of major complications support the valuable role of ERCP in the management of pediatric biliary and pancreatic diseases in the pediatric population.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in recurrent pancreatitis of pediatric asparaginase-associated pancreatitis

BACKGROUND

Asparaginase (ASP) is an important drug in combined chemotherapy regimens for pediatric acute lymphoblastic leukemia (ALL); ASP-associated pancreatitis (AAP) is the main adverse reaction of ASP. Recurrent pancreatitis is a complication of AAP, for which medication is ineffective.

AIM

To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in treating recurrent pancreatitis due to AAP.

METHODS

From May 2018 to August 2021, ten children (five males and five females; age range: 4-13 years) with AAP were treated using ERCP due to recurrent pancreatitis. Clinical data of the ten children were collected, including their sex, age, weight, ALL risk grading, clinical symptoms at the onset of pancreatitis, time from the first pancreatitis onset to ERCP, ERCP operation status, and postoperative complications. The symptomatic relief, weight change, and number of pancreatitis onsets before and after ERCP were compared.

RESULTS

The preoperative symptoms were abdominal pain, vomiting, inability to eat, weight loss of 2-7 kg, and 2-9 pancreatitis onsets. After the operation, nine of ten patients did not develop pancreatitis, had no abdominal pain, could eat normally; the remaining patient developed three pancreatitis onsets due to the continuous administration of ASP, but eating was not affected. The postoperative weight gain was 1.5-8 kg. There was one case of post ERCP pancreatitis and two cases of postoperative infections; all recovered after medication.

CONCLUSION

ERCP improved clinical symptoms and reduced the incidence of pancreatitis, and was shown to be a safe and effective method for improving the management of recurrent pancreatitis due to AAP.

Stone removal in a 5-year-old child with extrahepatic biliary obstruction using ERCP: A case report and a mini-review

Key Clinical Message

ERCP is a safe and effective method for managing biliary obstruction in children. A case report illustrates successful removal of a bile duct stone in a 5-year-old child using ERCP. Pediatric ERCP is a viable option for treating biliary diseases in well-equipped centers, alongside other approaches.

Abstract

We describe a 5-year-old child with extrahepatic biliary stone who successfully underwent endoscopic retrograde cholangiopancreatography for stone removal. He suffered from persistent colicky abdominal pain accompanied by fever that confirmed biliary stone. ERCP along with other methods, can be considered a safe procedure for managing BD in children.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children: A multicenter randomized controlled trial

BACKGROUND

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Currently, there is no suitable treatment for post-ERCP pancreatitis (PEP) prophylaxis. Few studies have prospectively evaluated interventions to prevent PEP in children.

AIM

To assess the efficacy and safety of the external use of mirabilite to prevent PEP in children.

METHODS

This multicenter, randomized controlled clinical trial enrolled patients with chronic pancreatitis scheduled for ERCP according to eligibility criteria. Patients were randomly divided into the external use of mirabilite group (external use of mirabilite in a bag on the projected abdominal area within 30 min before ERCP) and blank group. The primary outcome was the incidence of PEP. The secondary outcomes included the severity of PEP, abdominal pain scores, levels of serum inflammatory markers [tumor necrosis factor-alpha (TNF-α) and serum interleukin-10 (IL-10)], and intestinal barrier function markers [diamine oxidase (DAO), D-lactic acid, and endotoxin]. Additionally, the side effects of topical mirabilite were investigated.

RESULTS

A total of 234 patients were enrolled, including 117 in the external use of mirabilite group and the other 117 in the blank group. The pre-procedure and procedure-related factors were not significantly different between the two groups. The incidence of PEP in the external use of mirabilite group was significantly lower than that in the blank group (7.7% vs 26.5%, P < 0.001). The severity of PEP decreased in the mirabilite group (P = 0.023). At 24 h after the procedure, the visual analog scale score in the external use of mirabilite group was lower than that in the blank group (P = 0.001). Compared with those in the blank group, the TNF-α expressions were significantly lower and the IL-10 expressions were significantly higher at 24 h after the procedure in the external use of mirabilite group (P = 0.032 and P = 0.011, respectively). There were no significant differences in serum DAO, D-lactic acid, and endotoxin levels before and after ERCP between the two groups. No adverse effects of mirabilite were observed.

CONCLUSION

External use of mirabilite reduced the PEP occurrence. It significantly alleviated post-procedural pain and reduced inflammatory response. Our results favor the external use of mirabilite to prevent PEP in children.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

Temporal trend and factors associated with post-endoscopic retrograde cholangiopancreatography pancreatitis in children in the USA: a nationwide, retrospective cohort study

Pancreatitis is the most common adverse event following endoscopic retrograde cholangiopancreatography (ERCP). Meanwhile, the national temporal trend of post-ERCP pancreatitis (PEP) in children remains to be reported. The purpose of this study is to investigate the temporal trend and factors associated with PEP in children. We conducted a nationwide study using data from the National Inpatient Sample database during 2008-2017 and included all patients aged ≤ 18 years who underwent ERCP. The primary outcomes were temporal trends and factors associated with PEP. The secondary outcomes were in-hospital mortality, total charges (TC), and total length of stay (LOS). A total of 45,268 hospitalized pediatric patients who underwent ERCP were analyzed; of whom, 2043 (4.5%) were diagnosed with PEP. The prevalence of PEP decreased from 5.0% in 2008 to 4.6% in 2017 (P = 0.0002). In multivariable logistic analysis, adjusted risk factors of PEP were hospitals located in the West (aOR 2.09, 95% CI 1.36-3.20; P < .0001), bile duct stent insertion (aOR 1.49, 95% CI, 1.08-2.05; P = 0.0040), and end-stage renal disease (aOR 8.05, 95% CI 1.66-39.16; P = 0.0098). Adjusted protective factors of PEP were increasing age (aOR 0.95, 95% CI 0.92-0.98; P = 0.0014) and hospitals located in the South (aOR 0.53, 95% CI 0.30-0.94; P < .0001). In-hospital mortality, TC, and LOS were higher in patients with PEP than those without PEP.

CONCLUSION

This study shows a decreasing national trend over time and identifies multiple protective and risk factors for pediatric PEP. Endoscopists can use the insights from this study to evaluate relevant factors before performing ERCP in children to prevent PEP and reduce the medical-care burden.

WHAT IS KNOWN

• Although ERCP has become indispensable procedure in children as they are in adults, education and training programs for ERCP in children are underdeveloped in many countries. • PEP is the most common and most serious adverse event following ERCP. Research on PEP in adults showed rising hospital admission and mortality rates associated with PEP in the USA.

WHAT IS NEW

• The national temporal trend of PEP among pediatric patients in the USA was decreasing from 2008 to 2017. • Older age was a protective factor for PEP in children, while end-stage renal disease and stent insertion into the bile duct were risk factors.

Endoscopic Retrograde Cholangiopancreatography in Children: Feasibility, Success, and Safety with Standard Adult Endoscopes and Accessories

PURPOSE

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary and pancreatic diseases in the pediatric population was not well defined until recently. Our aim was to determine the feasibility, outcomes, and safety of ERCP in a local pediatric population, particularly using standard adult endoscopes and accessories.

METHODS

This retrospective study was conducted at the National Hospital of Sri Lanka. Pediatric patients (aged <16 years) who underwent ERCP from January 2015 to December 2020 were included in the study. Data, including patient demographics, indications for the procedure, technical details, and associated complications, were collected from the internal database and patient records maintained at the hospital.

RESULTS

The study included 62 patients who underwent a total of 98 ERCP procedures. All the procedures were performed by adult gastroenterologists using standard adult endoscopes and accessories. The mean age was 11.01±3.47 years. Pancreatic diseases were the major indications for most of the procedures (n=81, 82.7%), with chronic pancreatitis being the most common. Seventeen procedures (17.3%) were carried out for biliary diseases. Overall cannulation and technical success rates were 87.8% and 85.7%, respectively. Stent placement was the most common therapeutic intervention (n=66; 67.4%). Post-ERCP pancreatitis was the most common complication, occurring in eight patients (8.2%).

CONCLUSION

ERCP can be successfully and safely performed in pediatric populations using standard adult endoscopes and accessories with complications similar to those of adults. Adult ERCP services can be offered to most pediatric patients without additional costs of pediatric endoscopes and accessories.

Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used in the diagnosis and treatment of pancreaticobiliary system. ERCP is used less frequently in children than in adults due to the rarity of pancreaticobiliary diseases and technical difficulties. However, ERCP is a safe, effective diagnosis and treatment tool for children. Methods: All patients within the age range of 1-19 years, who underwent ERCP between 2010 and 2021 at our endoscopy unit, were retrospectively examined. Patient demographics, use of imaging methods, indications, type of sedation, interventions, success of ERCP, findings, and complications were evaluated. Results: Overall, 105 ERCPs were performed in 66 children (29 male and 37 female). The indications were choledocholithiasis, cyst hydatic, choledochal cyst, biliary atresia or anomaly, liver transplantation-related disorders, and pancreatic disorders, respectively. ERCP was finished as diagnostic ERCP in 20% and as therapeutic in 80%. Therapeutic procedures were sphincterotomy, stent placement or removal, stone or debris extraction, and balloon sweep or dilatation, respectively. The success rate in the procedures was 75.23%. The overall complication rate was 15.23%. Postprocedure pancreatitis occurred in 11.42%, hemorrhage occurred in 2.85%, and aggravation of cholangitis in 0.95%. All complications were managed conservatively. Conclusion: ERCP in pediatric patients is a safe procedure that can be performed by adult endoscopists with high success rates. Since our region is an endemic region for hydatid cyst disease, the most common ERCP indication after choledocholithiasis is procedures related to liver hydatid cyst disease. The most common complication was pancreatitis, and complications were treated medically.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in children

Gastrointestinal endoscopy is fundamental to diagnostic and therapeutic procedures in pediatric gastroenterology. In the decades since endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) for hepatobiliary and pancreatic disease were introduced into clinical practice, there has been increasing interest in these procedures, and practice guidelines and position papers that clearly define the role of ERCP and EUS in children have been published. Based on the distinction of endoscopy between children and adults, this review focuses on the current state of ERCP and EUS procedures in children, including the types of endoscopes used in children, general anesthesia and radiation exposure, biliary and pancreatic indications, considerations of education and training for ERCP and EUS procedures in children, and expectations for development of endoscopes for children.

Safety of endoscopic retrograde cholangiopancreatography in the pediatric population: a multicenter study

INTRODUCTION

The aims of this retrospective multicenter study were to assess the technical success and adverse events of endoscopic retrograde cholangiopancreatography (ERCP) procedures in children in French and Belgian centers.

METHODS

All children aged 1 day to 17 years who underwent ERCP between January 2008 and March 2019 in 15 tertiary care hospitals were retrospectively included.

RESULTS

271 children underwent 470 ERCP procedures. Clinical long-term follow-up was available for 72 % of our patients (340/470 procedures). The median age at intervention was 10.9 years. ERCP was therapeutic in 90 % (423/470) and diagnostic in cases of neonatal cholestasis in 10 % of the patients. The most common biliary indication was choledocholithiasis; the most common pancreatic indication was chronic pancreatitis. Biliary cannulation was successful in 92 % of cases (270/294); pancreatic cannulation in 96 % of cases (169/176); and planned therapeutic procedures in 92 % of cases (388/423). The overall complication rate was 19 % (65/340). The most common complication was post-ERCP pancreatitis (PEP) in 12 % of cases (40/340) and sepsis in 5 % (18/340). On univariate analyses, pancreatic stent removal was protective against PEP (odds ratio [OR] 0.1, 95 % confidence interval [CI] 0.01 - 0.75; P = 0.03), and sepsis was associated with history of liver transplantation (OR 7.27, 95 %CI 1.7 - 31.05; P = 0.01). Five patients had post-ERCP hemorrhage and two had intestinal perforation. All complications were managed with supportive medical care. There was no procedure-related mortality.

CONCLUSION

Our cohort demonstrates that ERCP can be performed safely with high success rates in many pancreaticobiliary diseases of children. The rate of adverse events was similar to that in previous reports.

Fifteen-Year Single-Center Experience of Biliary Complications in Liver Trauma Patients: Changes in the Management of Posttraumatic Bile Leak

INTRODUCTION

 Management of posttraumatic bile leak has evolved over time in our unit, from endoscopic retrograde cholangiopancreatography (ERCP) stenting to intraperitoneal drainage (IPD) alone as first-line treatment for intraperitoneal bile leak.

MATERIALS AND METHODS

 Retrospective review of liver trauma patients from 2002 to 2017. Demographics, time and mode of diagnosis of bile leak, management, and outcome were analyzed of the box plot.

RESULTS

 In 118 patients, there were 28 traumatic bile leaks. Eighteen were free intraperitoneal and 10 were localized bilomas. The median time of diagnosis was 6 days following injury. The modes of diagnosis were preemptive hepatobiliary scintigraphy (18), computed tomography (CT) or ultrasound (7), and laparotomy (3). Free intraperitoneal biliary leak management included 11 IPD alone, 3 IPD plus ERCP, 2 IPD plus transcystic biliary stent (TBS), 1 operative cholangiogram, and 1 no intervention. Median time of IPD duration was 7 days (4-95) in IPD alone versus 14 days (6-40) in IPD + ERCP/TBS (p = 0.3). Median inpatient length of stay was 13 days (8-44) in IPD alone versus 12 days (8-22) in IPD + ERCP/TBS (p = 0.4).

CONCLUSION

 Placement of IPD alone, as first-line treatment, is safe and effective in the management of intraperitoneal bile leaks, avoiding the costs and potential complications of ERCP.

Endoscopic retrograde cholangiopancreatography in infants and children

Background and study aims  Previous reports have suggested that endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients are safe. However, the total number of cases presented in the literature remains small. We present results regarding safety and outcomes in pediatric patients undergoing ERCP at Oslo University Hospital. Patients and methods  Patients < 18 years who underwent ERCP between April 1999 and November 2017 were identified using procedure codes. Medical records were examined for age, gender, diagnosis, indications, type of sedation, findings, interventions, and complications. Results  A total of 244 procedures were performed in 158 patients. Fifty-six of these were in 53 infants (age ≤ 1 year). Mean age was 8.8 years. The youngest patient was 8 days old. Mean weight was 5.0 kg in infants, the smallest weighing 2.9 kg. Cannulation failed in 19 (7.8 %). The main indication in infants was suspicion of biliary atresia (n = 38). Six of the procedures (10.7 %) were therapeutic. In children the main indications were biliary stricture (n = 64) and investigation of primary sclerosing cholangitis (PSC) (n = 45). 119 (63.2 %) of these procedures were therapeutic. Complications were uncommon in infants; only two episodes of infection were registered. In children (> 1 year) post-ERCP pancreatitis were seen in 10.4 %. Conclusions  Our retrospective series of ERCP procedures includes 56 procedures in infants, which is one of the largest series presented. Complications in infants are rare and post-ERCP pancreatitis was not seen. In older children 10.4 % experienced post-ERCP pancreatitis. In expert hands, ERCP was shown to be acceptably feasible and safe in infants and children.

Pancreatic ascites and Pleural Effusion in Children: Clinical Profile, Management and Outcomes

BACKGROUND

Pancreatic ascites (PA) and pleural effusion (PPE) are rarely encountered in children. They develop due to disruption of the pancreatic duct (PD) or leakage from an associated pancreatic fluid collection (PFC). The literature on childhood PA/PPE and its management is scarce.

METHODS

A retrospective review of children with PA/PPE diagnosed and managed at our center over the last 4 years was performed. The clinical, biochemical, radiological and management profiles were analyzed. Conservative management included nil per oral, octreotide and drainage using either percutaneous catheter or repeated paracentesis. Endotherapy included endoscopic retrograde cholangiopancreatography (ERCP) and transpapillary stenting.

RESULTS

Of the 214 children with pancreatitis, 15 (7%) had PA/PPE. Median age was 9 years with a third under 2 years. Median ascitic fluid amylase was 8840 U/L and all had elevated protein (>2.5 g/dl) and low serum ascites-albumin gradient ascites (<1.1). While PA/PPE was the first manifestation of underlying chronic pancreatitis (CP) in 10 children (67%), trauma was seen in 4 (26%) and hypertriglyceridemia in 1 (7%). On imaging, PD disruption could be identified in 10 (67%) children. ERCP and stenting was done in 10 children. Conservative management alone (n = 4) and endotherapy (n = 10) was successful in 93% with only one requiring surgery. The younger children (n = 4), were managed conservatively and only 1 of them required surgery. Resolution of PA/PPE was achieved in all with no recurrences.

CONCLUSIONS

Conservative management and ERCP plus transpapillary stenting results in resolution of majority of pediatric PA/PPE. Children presenting with PA/PPE needs to be evaluated for CP.

Prevalence and Factors Associated with Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in Children

BACKGROUND

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP).

AIM

To assess the prevalence and factors associated with post-ERCP pancreatitis (PEP) in a Chinese pediatric population.

METHODS

Sixty-six children who underwent ERCP between March 2018 and March 2019 at Shanghai Children's Medical Center were retrospectively recruited for the study. Clinical data, including demographics, indications, comorbidities, and procedural data, were reviewed to identify the prevalence and factors associated with PEP.

RESULTS

Ninety-two ERCPs were performed on 66 pediatric patients aged from 8 months to 14 years. The indications for ERCP were chronic pancreatitis (49, 53.2%), pancreaticobiliary maljunction (19, 20.7%), pancreas divisum (19, 20.7%), and pancreatic pseudocyst (5, 5.4%). All ERCPs were performed for therapeutic purposes. PEP was identified in 19 (20.7%) patients; there were ten mild cases, eight moderate cases, and one severe case. The univariate analysis revealed that a history of chronic pancreatitis was negatively associated with PEP (P = 0.033), and sphincterotomy was positively associated with PEP (P = 0.01). The multivariate analysis showed that sphincterotomy was a risk factor for PEP (P = 0.017, OR 4.17; 95% CI, 1.29, 13.54).

CONCLUSIONS

Our data revealed a high prevalence of PEP in a Chinese pediatric population. Chronic pancreatitis was a protective factor, and sphincterotomy was a risk factor for PEP development.

Pancreaticopleural fistula in children with chronic pancreatitis: a case report and literature review

BACKGROUND

Pancreaticopleural fistula (PPF) is a very rare and critical complication of pancreatitis in children. The majority of publications relevant to PPF are case reports. No pooled analyses of PPF cases are available. Little is known about the pathogenesis and optimal therapeutic schedule. The purpose of this study was to identify the pathogenesis and optimal therapeutic schedule of PPF in children.

CASE PRESENTATION

The patient was a 13-year-old girl who suffered from intermittent chest tightness and dyspnea for more than 3 months; she was found to have chronic pancreatitis complicated by PPF. The genetic screening revealed SPINK1 mutation. She was treated with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde pancreatic drainage (ERPD); her symptoms improved dramatically after the procedures.

CONCLUSIONS

PPF is a rare pancreatic complication in children and causes significant pulmonary symptoms that can be misdiagnosed frequently. PPF in children is mainly associated with chronic pancreatitis (CP); therefore, we highlight the importance of genetic testing. Endoscopic treatment is recommended when conservative treatment is ineffective.

Successful Therapeutic ERCP in a 99-Day-Old Child With Common Bile Duct Stones: A Case Report and Discussions on the Particularities of the ERCP in Children

Backgroud: At present, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has gradually been used in the diagnosis and treatment of biliary and pancreatic diseases in children, but reports on and the application of ERCP in children, especially in infants, are still highly limited. Case Presentation: This case report describes a 99-day-old infant with choledocholithiasis who successfully underwent ERCP to relieve an obstruction. The infant developed obstructive jaundice during chemotherapy for a malignant tumor, and a routine blood examination showed signs of infection. Liver damage also occurred. B-ultrasound suggested stones in the lower segment of the common bile duct (CBD). After sufficient communication and preparation, biliary drainage was successfully carried out in the infant using adult duodenoscope (JF240) and related instruments with cooperation from the Department of Anesthesiology. Conclusions: This paper preliminarily introduces our experience with adult duodenoscope in children, providing a good example for hospitals without a special duodenoscope for children to carry out pediatric ERCP. Clinicians should pay close attention to the need of careful use of ERCP in infants.

ERCP in babies: Low risk of post-ERCP pancreatitis - results from a multicentre survey

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is rarely performed in newborns, and the risk of post-ERCP pancreatitis (PEP) has not been defined in this age group. We therefore performed a European multicentre analysis of PEP rates and risk factors in children aged ≤1 year.

PATIENTS AND METHODS

Based on a sample size estimation, 135 consecutive ERCPs in 126 children aged ≤1 year were evaluated from five European centres, and the first ERCP per child analysed. All ERCPs and clinical reports were reviewed manually for PEP and associated risk factors. All ERCPs were performed by endoscopists with high ERCP expertise.

RESULTS

No PEP was observed (0/126, 0.0%, CI 0-2.9%) despite the formal presence of multiple risk factors and despite lack of PEP prophylaxis (except one patient having received a pancreatic duct stent). The PEP rate was significantly lower than the PEP rate expected in adults with similar risk factors.

CONCLUSIONS

ERCP in children aged ≤1 year is safe in terms of PEP. The PEP risk is significantly lower in children aged ≤1 year than in adults, therefore no PEP prophylaxis seems to be needed in young children. Risk factors from adults may not apply to children under 1 year. Reluctance to perform diagnostic ERCP in suspected biliary anomalies should not be based on presumed PEP risk.

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.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Endoscopic treatment of chronic pancreatitis in pediatric population: Long-term efficacy and safety

Background

Chronic pancreatitis (CP) in children is an inreasingly recognized disease.

Objective

The purpose of study was to analyse the safety and long-term efficacy of endoscopic treatment in children with CP.

Methods

Records of 38 patients aged <18 years, referred to the Digestive Endoscopy Unit at Catholic University, Fondazione Policlinico "A. Gemelli" IRCCS between 1991 and 2017, were reviewed. Abdominal pain, analgesia and number of episodes of acute pancreatitis in the pre- and post- endoscopic retrograde cholangiopancreatography (ERCP) period were evaluated. Need for surgery was assessed. Therapeutic intervention data and complications were interrogated.

Results

In total 158 ERCPs were performed. Median post-ERCP follow-up was 7 years. The majority of patients had CP type IV (47%) and type Ib (37%) (Cremer's classification). Major papilla pancreatic sphincterotomy was performed in 47%, major and minor in 24% and minor in 29% of patients. Stones/plugs were removed in at least one ERCPs in 66% individuals. Eleven out of 38 patients had stricture of the pancreatic duct; these were dilated and stented in 5/11 and stented in 6/11. Five complications were recorded (3%). Severity and frequency of abdominal pain improved significantly; p < 0.001. Use of analgesia and number of episodes of acute pancreatitis decreased significantly; p < 0.001. One child required subsequent surgery.

Conclusion

Endoscopic management of symptomatic CP in children is safe and effective.