Technological imbalance: seeking a small-caliber duodenoscope

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Influence of pediatric ERCP positioning on procedural outcomes: A single-center study

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally done in the prone position. In pediatrics, patient anatomy and anesthesia practices are considerations that affect procedural success and anesthesia time. The aim of our study was to evaluate the safety, procedural success, and efficiency of pediatric ERCP in the prone versus supine positions.

METHODS

ERCPs from September 2016 to August 2023 were reviewed at our center. Demographic and procedure variables were collected. Multivariate linear regression was performed to determine the effect of patient position on total anesthesia time.

RESULTS

Two hundred and eighty-three patients (378 ERCPs) were included. There were significant differences in fellow involvement, proportion of native papillae, procedural indication, and total anesthesia time by ERCP position. Multivariate linear regression found that supine position was associated with 9.3-min decrease in anesthesia time and American Society of Anesthesiologists Class 1 or 2 was associated with 10.6-min decrease in anesthesia time. Factors that were associated with increased anesthesia time were additional procedure, increased procedure time, and native papilla. Finally, we found a learning curve for transitioning from prone to supine position was between 10 and 40 cases. After the learning curve, we found 11-min decrease in mean procedure time and 16-min decrease in total anesthesia time in the supine position.

CONCLUSIONS

This is the first pediatric study to evaluate the role of patient positioning on ERCP outcomes and total anesthesia time. Given similar procedural outcomes, the impact of increased anesthesia time on neurodevelopment in children, and the cost to the patient, the supine position may be preferred to a prone position.

Use of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Management of Pediatric Pancreatic Injury

BACKGROUND

ERCP is the gold standard for evaluating the integrity of the main pancreatic duct (MPD); however, ERCP is underutilized in evaluating MPD integrity in pediatric blunt pediatric injury. The primary aim of this study was to evaluate the discordance of cross-sectional imaging (CSI) and ERCP in children with suspected MPD injury.

METHODS

A retrospective review of all patients age ≤18 years with CSI or clinical findings suggestive of MPD injury (MPDI) and ERCP was conducted at a level I pediatric trauma center from January 2009 to May 2023. Demographic and clinical data were collected. Pancreatic injury findings were compared between cross-sectional imaging and ERCP.

RESULTS

An ERCP was performed in 28 patients with suspected MPDI with a mean age of 7 ± 4.5 years and weight of 25.0 ± 13.6 kg. Based on initial CSI, 23 patients had a suspected MPDI, and 5 had concern for MPDI based on clinical findings. ERCP differed from CSI findings in 39% of patients: 7 with CSI evidence of MPDI without injury on ERCP and 4 patients without imaging concern of MPDI but demonstrated injury on ERCP. Findings on ERCP guided surgical management in 71% (20/28) of patients due to location and completeness of MPDI. All patients without MPDI were managed nonoperatively.

CONCLUSION

Approximately 40% of patients had discordant findings between ERCP and CSI. ERCP can aide in surgical management decision making. All patients with a partial MPDI were managed with endoscopic therapy alone. ERCP should be considered when assessing a child with a suspected MPDI.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Diagnostic Study.

Expedited Laparoscopic Cholangiogram and Liver Biopsy in the Workup of Biliary Atresia

PURPOSE

Recent studies demonstrate the success of Kasai portoenterostomy for biliary atresia (BA) is linearly related to infant age at time of Kasai. We sought to review the feasibility and safety of laparoscopic needle micropuncture cholangiogram with concurrent core liver biopsy (if needed) for expedited exclusion of BA in patients with direct conjugated hyperbilirubinemia.

METHODS

Expedited laparoscopic cholangiogram and liver biopsy were instituted at our facility for infants with direct hyperbilirubinemia for whom clinical exam and laboratory workup failed to diagnose. A retrospective chart review was performed in infants <1 year with hyperbilirubinemia from 2016 to 2021. Demographics, preoperative evaluation, procedure details, and complications were reviewed.

RESULTS

Two hundred ninety-seven infants with unspecified jaundice were identified, of which, 86 (29%) required liver biopsy. Forty-seven percutaneous liver biopsies were obtained including 8 (17%) in whom BA could not be excluded. Laparoscopic cholangiogram was attempted in 47 infants following basic workup; BA was diagnosed in 22 infants (47%) of which 3 were <18 days old. Biliary patency was demonstrated laparoscopically in 22 of 25 (88%); 3 (12%) required conversion to open cholangiogram. Infants with percutaneous liver biopsy had an average delay of 3 days (range: 2-36) to cholangiogram. Preoperative studies and liver biopsy alone did not reliably exclude the diagnosis of BA.

CONCLUSION

Laparoscopic cholangiogram with liver biopsy is a safe procedure resulting in the confirmation or exclusion of BA in infants. Forty-seven percent of infants who underwent laparoscopic cholangiogram were found to have BA; those who were surgical candidates underwent Kasai during the same operation.

Endotherapy in pediatric pancreatitis

PURPOSE OF REVIEW

Some children with acute recurrent and chronic pancreatitis stand to benefit from therapeutic endoscopic interventions. The purpose of this review is to summarize specific endoscopic therapies used for these conditions and highlight areas of future research.

RECENT FINDINGS

Multicenter collaboration and consortium efforts have provided more data now than ever on the technical outcomes and safety of therapeutic endoscopic procedures for pancreatitis in children. Indications are growing but more research is needed to help guide patient selection.

SUMMARY

Advanced endoscopic procedures including endoscopic retrograde cholangiopancreatography, endoscopic-ultrasound guided therapies, and single-operator pancreatoscopy may be used in patients with acute recurrent or chronic pancreatitis to manage pancreatic duct obstruction or local complications including pseudocysts and walled-off necrosis. Patient and procedural factors differ between adults and children. Access to these procedures for younger children is growing, and technical outcomes and adverse event rates appear similar between adults and children.

Pediatric ERCP in the Setting of Acute Pancreatitis: A Secondary Analysis of an International Multicenter Cohort Study

Previous studies have demonstrated the safety of performing endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population; however, few have addressed the outcomes of children undergoing ERCP during acute pancreatitis (AP). We hypothesize that ERCP performed in the setting of AP can be executed with similar technical success and adverse event profiles to those in pediatric patients without pancreatitis. Using the Pediatric ERCP Database Initiative, a multi-national and multi-institutional prospectively collected dataset, we analyzed 1124 ERCPs. One hundred and ninety-four (17%) of these procedures were performed in the setting of AP. There were no difference in the procedure success rate, procedure time, cannulation time, fluoroscopy time, or American Society of Anesthesiology class despite patients with AP having higher American Society of Gastrointestinal Endoscopy grading difficulty scores. This study suggests that ERCP can be safely and efficiently performed in pediatric patients with AP when appropriately indicated.