Pediatric Endoscopic Procedure Complications

Pediatric endoscopic ultrasound-guided liver biopsy: 3-year experience

OBJECTIVES

Liver biopsy is the gold standard for diagnosing and staging liver diseases. Endoscopic ultrasound-guided liver biopsy (EUS-LB) has been reported in adults with equivalent or better safety profiles than percutaneous liver biopsies. The aim of this study was to retrospectively assess the safety and efficacy of EUS-LB in pediatric patients.

METHODS

This was a retrospective chart review of consecutive pediatric patients undergoing EUS-LB at Cincinnati Children's Hospital Medical Center from March 2020 to April 2023. Patients ≤21 years old were included. EUS-LB was performed via fine-needle biopsy technique with transduodenal and/or transgastric approach. Histology was independently reviewed by one of two expert pathologists, including length (cm) and complete portal tract (CPT) number per the American Association for the Study of Liver Diseases (AASLD) adequacy criteria. Demographics, clinical data, technical information, diagnostic success, and adverse events were recorded.

RESULTS

Eighty-three patients were included in the analysis, with various indications that required liver biopsy. All biopsies achieved diagnostic and technical success, with 77 (93%) meeting both AASLD criteria for adequacy. Most patients (57, 69%) underwent biopsy of both hepatic lobes, with an overall median of two needle passes. Total specimen length was a median of 7.9 cm (interquartile range [IQR] 5.2-10.3), and the median maximum intact specimen was 4.2 cm (IQR 3.1-5.4). The median CPT number was 24 (IQR 17-32) per patient. Four mild adverse events (5%) occurred; none involved bleeding.

CONCLUSIONS

EUS-LB was well tolerated and yielded samples that were technically and diagnostically successful in a pediatric population, with comparable safety to percutaneous liver biopsy.

Serological testing for celiac disease in children

INTRODUCTION

Celiac disease is one of the most common chronic immune-mediated gastrointestinal conditions, characterized by the presence of disease-specific serum antibodies against self-antigen transglutaminase 2. Even though modern serological assays can identify most untreated celiac disease patients and are also increasingly being used to establish a diagnosis, several challenges are associated with the tests, including a lack of standardization, the variable sensitivity and specificity of commercial assays, and inadequate sensitivity for monitoring adherence to a gluten-free diet.

AREAS COVERED

This narrative review outlines the current use of serological tests in case-finding and screening, as well as in the follow-up of dietary treatment. Additionally, the possible challenges and pitfalls of serological tests, along with future directions, are addressed.

EXPERT OPINION

The excellent accuracy of modern autoantibody tests, especially for greatly elevated levels of transglutaminase 2 antibodies and positive endomysial antibodies, enables using serological testing in establishing a diagnosis. However, better international standardization of the assays is required, the necessity of endomysial antibody testing needs to be further scrutinized, and additional research is needed to improve noninvasive tools for follow-up and to further expand the no-biopsy criteria for celiac disease.

Semiautomated electronic medical record based system for monitoring delayed adverse events in pediatric endoscopy and sedation

OBJECTIVE

To develop a semiautomated electronic medical record (EMR) system to track pediatric endoscopic procedural adverse event (AE) at a tertiary referral children's hospital.

METHODS

We developed an automated EMR based query for postprocedure AEs. Main outcome measurements within 30 days of procedure: return to emergency department, return to surgery, unplanned admissions and admissions with longer than intended stays. Events were graded using a recently described classification system for postendoscopy events and tracked for a 36-month period, from January 2017 to December 2019.

RESULTS

Development of a semi-automated system was successful in comprehensive identification of endoscopy and sedation related AE. A total of 193 AEs (2%) were identified in all three categories. Seventy cases (0.7%) were noted to be a direct result of an endoscopic procedure. Of these cases, 31 (44%) were noted to be Grade 3, 5 cases (7%) Grade 4, and no Grade 5 AE occured. Higher rates of AE were observed after therapeutic procedures versus diagnostic (2.6% vs. 0.3%, p = <0.00001). AEs related to sedation occurred in 0.5% of procedures with the majority (84%) reported in patients with American Society of Anesthesia classification of 3 or greater.

CONCLUSIONS

Diagnostic endoscopy remains a safe procedure and risk of both endoscopy and sedation related AE are low. Therapeutic procedures carry a higher risk but are still overwhelmingly safe. Institutional investment in this EMR based system allowed for sustainability and comprehensive tracking of endoscopy related AE.

Promoting Research that Supports High-Quality Gastrointestinal Endoscopy in Children

PURPOSE OF REVIEW

Defining and measuring the quality of endoscopic care is a key component of performing gastrointestinal endoscopy in children. The purpose of this review is to discuss quality metrics for pediatric gastrointestinal endoscopy and identify where additional research is needed.

RECENT FINDINGS

Pediatric-specific standards and indicators were recently defined by the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group through a rigorous guideline consensus process. Although the aim of these guidelines is to facilitate best practices for safe and high-quality gastrointestinal endoscopy in children, they highlight the pressing need to expand upon the body of evidence supporting these standards and indicators as predictors of clinically relevant outcomes. In this review, we propose and discuss ideas for several high-yield research topics to engage pediatric endoscopists and promote best practices in pediatric endoscopy.

Identification of Iatrogenic Perforation in Pediatric Gastrointestinal Endoscopy

OBJECTIVES

Iatrogenic viscus perforation in pediatric gastrointestinal endoscopy (GIE) is a very rare, yet potentially life-threatening event. There are no evidence-based recommendations relating to immediate post-procedure follow-up to identify perforations and allow for timely management. This study aims to characterize the presentation of children with post-GIE perforation to better rationalize post-procedure recommendations.

METHODS

Retrospective study based on unrestricted pooled data from centers throughout Europe, North America, and the Middle East affiliated with the Endoscopy Special Interest Groups of European Society for Paediatric Gastroenterology Hepatology and Nutrition and North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Procedural and patient data relating to clinical presentation of the perforation were recorded on standardized REDCap case-report forms.

RESULTS

Fifty-nine cases of viscus perforation were recorded [median age 6 years (interquartile range 3-13)]; 29 of 59 (49%) occurred following esophagogastroduodenoscopy, 26 of 59 (44%) following ileocolonoscopy, with 2 of 59 (3%) cases each following balloon enteroscopy and endoscopic retrograde cholangiopancreatography; 28 of 59 (48%) of perforations were identified during the procedure [26/28 (93%) endoscopically, 2/28 (7%) by fluoroscopy], and a further 5 of 59 (9%) identified within 4 hours. Overall 80% of perforations were identified within 12 hours. Among perforations identified subsequent to the procedure 19 of 31 (61%) presented with pain, 16 of 31 (52%) presented with fever, and 10 of 31 (32%) presented with abdominal rigidity or dyspnea; 30 of 59 (51%) were managed surgically, 17 of 59 (29%) managed conservatively, and 9 of 59 (15%) endoscopically; 4 of 59 (7%) patients died, all following esophageal perforation.

CONCLUSIONS

Iatrogenic perforation was identified immediately in over half of cases and in 80% of cases within 12 hours. This novel data can be utilized to generate guiding principles of post-procedural follow-up and monitoring.

PLAIN LANGUAGE SUMMARY

Bowel perforation following pediatric gastrointestinal endoscopy is very rare with no evidence to base post-procedure follow-up for high-risk procedures. We found that half were identified immediately with the large majority identified within 12 hours, mostly due to pain and fever.

Pre-endoscopy Symptoms and Age, But Not Esophageal Biopsy Number Are Associated With Post-endoscopy Adverse Events

Esophagogastroduodenoscopy (EGD) is a frequently utilized investigative tool in the management of gastrointestinal conditions in children. Biopsies obtained during EGD may pose risk for post-operative adverse events (AEs), and further understanding of risk is imperative to provide informed consent to families and safe patient care. In particular, the impact of biopsy number and location on the development of AEs has not been studied in pediatric patients. We prospectively assessed for AEs by telephone survey 3-7 days after 209 EGDs performed on patients ages 1-21 years over a 1-year period. Demographic, endoscopic, and histologic data were collected. The most common symptoms reported were throat pain (61%), chest pain (26%), and dysphagia (26%). Binary regression models identified age and pre-operative symptoms as factors that influenced the likelihood of post-operative morbidity. Multiple biopsies from 3 different locations of the esophagus did not impact the risk of post-operative AEs.

Application of imaging techniques in pancreaticobiliary maljunction

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

Nationwide survey of pediatric gastrointestinal endoscopy in Japan

BACKGROUND AND AIM

The implementation rates of pediatric gastrointestinal endoscopy are increasing with advancements in the devices used and pediatricians' skills. As part of the Japan Pediatric Endoscopy Study Group, we aimed to investigate the rates of pediatric gastrointestinal endoscopy use and the associated adverse events through a nationwide survey.

METHODS

A questionnaire was sent to 630 institutions in Japan. The numbers of pediatric gastrointestinal endoscopy cases and adverse events occurring during endoscopy, from April 2011 to March 2016, were investigated.

RESULTS

Responses were obtained from 445 facilities. The total number of pediatric gastrointestinal endoscopies was 37 447 and that of endoscopic examinations was 32 219 (86.0%), with esophagogastroduodenoscopy accounting for 18 484 cases; ileal colonoscopy, 11 936; endoscopic retrograde cholangiopancreatography, 389; wireless capsule endoscopy, 897; and balloon-assisted enteroscopy, 513. The number of endoscopic treatments was 5228, followed by balloon dilatation (1703), foreign body removal (989), and polypectomy (822); 201 adverse events (0.54%) occurred, 79 of which presented during endoscopic examination (0.25%). Eight serious perforations were noted in 0.0054% and 0.025% of those undergoing esophagogastroduodenoscopy and colonoscopy, respectively. Overall, 122 adverse events (2.33%) occurred in association with endoscopic treatment. One case of cardiopulmonary arrest occurred because of accidental extubation. However, no deaths occurred.

CONCLUSION

Endoscopic examinations had a slightly higher adverse event rate, because of an increase in endoscopic retrograde cholangiopancreatography and small intestine enteroscopy, than that reported in previous studies, but the adverse event rate of endoscopic treatment did not increase.

Evolution in the Practice of Pediatric Endoscopy and Sedation

The fields of pediatric gastrointestinal endoscopy and sedation are critically important to the diagnosis and treatment of gastrointestinal (GI) disease in children. Since its inception in the 1970s, pediatric endoscopy has benefitted from tremendous technological innovation related to the design of the endoscope and its associated equipment. Not only that, but expertise among pediatric gastroenterologists has moved the field forward to include a full complement of diagnostic and therapeutic endoscopic procedures in children. In this review, we discuss the remarkable history of pediatric endoscopy and highlight current limitations and future advances in the practice and technology of pediatric endoscopy and sedation.

Gastrointestinal Endoscopy in the Neonate

Gastrointestinal endoscopy permits direct observation of the alimentary tract, acquisition of mucosal tissue for histopathologic examination, and other diagnostic and therapeutic maneuvers. Endoscopes of appropriate size for many neonates and an expanding array of compatible tools and accessories have broadened what is possible, although few neonatal data exist to guide use. Evaluation and treatment of gastrointestinal bleeding, evaluation and dilation of fibromuscular congenital esophageal stenosis, and the bedside placement of gastrostomy tube have been described. Careful consideration of risks, benefits, and discussions between involved specialties permit patient-specific application of these tools and techniques to augment care of this vulnerable population.

Endoscopic retrograde cholangiopancreatography in children with symptomatic pancreaticobiliary maljunction: A retrospective multicenter study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in pediatric patients with cholangiopancreatic diseases.

AIM

To evaluate the efficacy, safety, and long-term follow-up results of ERCP in symptomatic pancreaticobiliary maljunction (PBM).

METHODS

A multicenter, retrospective study was conducted on 75 pediatric patients who were diagnosed with PBM and underwent therapeutic ERCP at three endoscopy centers between January 2008 and March 2019. They were divided into four PBM groups based on the fluoroscopy in ERCP. Their clinical characteristics, specific ERCP procedures, adverse events, and long-term follow-up results were retrospectively reviewed.

RESULTS

Totally, 112 ERCPs were performed on the 75 children with symptomatic PBM. Clinical manifestations included abdominal pain (62/75, 82.7%), vomiting (35/75, 46.7%), acholic stool (4/75, 5.3%), fever (3/75, 4.0%), acute pancreatitis (47/75, 62.7%), hyperbilirubinemia (13/75, 17.3%), and elevated liver enzymes (22/75, 29.3%). ERCP interventions included endoscopic sphincterotomy, endoscopic retrograde biliary or pancreatic drainage, stone extraction, etc. Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis (9/75, 12.0%), gastrointestinal bleeding (1/75, 1.3%), and infection (2/75, 2.7%). During a mean follow-up period of 46 mo (range: 2 to 134 mo), ERCP therapy alleviated the biliary obstruction and reduced the incidence of pancreatitis. The overall effective rate of ERCP therapy was 82.4%; seven patients (9.3%) were lost to follow-up, eight (11.8%) re-experienced pancreatitis, and eleven (16.2%) underwent radical surgery, known as prophylactic excision of the extrahepatic bile duct and hepaticojejunostomy.

CONCLUSION

ERCP is a safe and effective treatment option to relieve biliary or pancreatic obstruction in symptomatic PBM, with the characteristics of minor trauma, fewer complications, and repeatability.

Magnetically Controlled Capsule Endoscopy in Children: A Single-center, Retrospective Cohort Study

OBJECTIVE

Capsule endoscopy (CE) is a noninvasive diagnostic tool for the digestive tract. We aim to investigate the feasibility and safety of newly developed magnetically controlled capsule endoscopy (MCE) in children.

METHODS

A total of 129 children who underwent MCE in Shanghai Children's Hospital were retrospectively recruited between March 2016 and August 2018. The feasibility, positive findings, and safety of MCE were evaluated and systematically analyzed.

RESULTS

Of all those children, 68 were boys, and 61 were girls with a mean age of 9.8 ± 1.9 years (6-14 years). The MCE procedure was feasible in all children. The mean esophageal transit time was 6.0 ± 4.6 seconds. The mean gastric examination time was 14.4 ± 3.9 minutes, and the average gastric transit time was 83.9 ± 59.1 minutes. Positive findings were detected in 82 children (82/129, 63.6%), 1 had esophageal lesions, 30 had superficial gastritis, 14 had superficial gastritis with bile reflux, 18 had nodular gastritis, 1 had ulcers, and 2 had heterotopic pancreas. There were 5 patients who had duodenal bulbar ulcers. One had lymphatic follicle, 1 had celiac disease, 1 had blue rubber bleb nevus syndrome, and 2 polyps were detected in 16 patients who were examined the small bowel. No serious adverse event was reported during the MCE examination and follow-up, and all subjects excreted the capsules spontaneously within 2 weeks.

CONCLUSIONS

We showed that MCE is feasible and safe in children above 6 years. More studies are needed to further investigate the efficacy of MCE in children.