Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in children

Minimal endoscopic sphincterotomy followed by papillary balloon dilation to relieve choledocholithiasis in a 6-year-old girl with hereditary spherocytosis

A 6-year-old girl previously diagnosed with hereditary spherocytosis was admitted to our hospital with gallstones and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and fluoroscopy revealed a dilated common bile duct (CBD) without evident stones, possibly due to spontaneous excretion through the papilla of Vater. A 7-French plastic stent was inserted into the CBD. After the procedure, a marked increase in pancreatic enzyme levels was observed, and she was diagnosed with post-ERCP pancreatitis (PEP). Stent placement could have been a cause of pancreatitis; therefore, we removed the stent. Subsequently, recovery from pancreatitis was confirmed, although she suddenly complained of abdominal pain and was diagnosed with choledocholithiasis recurrence. ERCP was repeated, and fluoroscopy revealed a dilated CBD with a stone. A minimal endoscopic sphincterotomy (EST) was performed to reduce the risk of PEP, and a biliary dilation balloon placed across the papilla was gradually inflated until the waist of the balloon disappeared. Stones were extracted using a retrieval balloon catheter. The abdominal pain resolved immediately, and the patient recovered without developing PEP. To our knowledge, this is the first case report of a pediatric patient treated with minimal EST followed by papillary balloon dilation for choledocholithiasis.

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.

Mini-probe endoscopic ultrasound for the diagnosis of congenital esophageal or duodenal stenosis

PURPOSE

The usefulness of endoscopic ultrasound (EUS) in pediatric populations has been recently appreciated; however, published studies on mini-probe EUS in the diagnosis of congenital esophageal stenosis (CES) or congenital duodenal stenosis (CDS) in pre-school patients remain scarce. This study aimed to report the utility of mini-probe EUS for the diagnosis of CES or CDS in pre-school patients based on the etiology.

METHODS

We retrospectively reviewed the medical records of pediatric patients with CES or CDS who underwent mini-probe EUS through the stenotic segments at our hospital between December 2006 and December 2021.

RESULTS

Five patients with CES and one with CDS were enrolled. The median age and body weight when EUS was performed were 12.5 months and 8.5 kg, respectively. Hypoechoic lesions were observed on EUS in three patients, which were assessed as cartilage; one patient had no hypoechoic lesion but had a focal thickness of the muscular layer. They were diagnosed with tracheobronchial remnants based on EUS. The full circumferential wall thickness of the esophagus was visualized in one patient with fibromuscular hypertrophy. The histopathological findings confirmed the diagnoses. In the patient with CDS, EUS findings revealed pancreatic parenchyma encircling the stenotic part of the duodenum. The preoperative diagnosis was annular pancreas. The patient underwent duodenoduodenostomy, and intraoperative findings confirmed the diagnosis.

CONCLUSION

Mini-probe EUS can be recommended as a feasible and safe technique for infants and toddlers. It can effectively diagnose CES or CDS based on etiology and can inform treatment strategies for pre-school patients.

Expanding the Use of Endoscopic Retrograde Cholangiopancreatography in Pediatrics: A National Database Analysis of Demographics and Complication Rates

Background

This study aimed to aid in risk assessment of pediatric endoscopic retrograde cholangiopancreatography (ERCP) candidates by utilizing a national pediatric database with a large sample to assess how patient characteristics may affect ERCP complication rates.

Methods

The Kids' Inpatient Database (KID) is a sample of pediatric discharges in states participating in the Healthcare Cost and Utilization Project (HCUP). This database provides demographic information, hospitalization duration, and outcome information for hospitalizations during which an ERCP occurred. International Classification of Diseases (ICD) codes were used to determine the hospitalization indication. ERCP complication rate was ascertained via ICD codes. All statistical analyses were performed using SAS 9.4.

Results

Complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. This analysis captured a large Hispanic population, specifically in the South and West regions. Gallbladder calculus and cholecystitis were more likely to occur in females. A higher percentage of patients in the age 10 - 17 group were female (72.2% vs. 52.7%, P < 0.01) and Hispanic (33.4% vs. 22.7%, P < 0.01) compared to the age 0 - 9 group. Age 0 - 5 and male gender were associated with lower routine home discharge rates and longer lengths of stay. Complications occurred at a higher rate in ages 0 - 5, though the difference was not statistically significant.

Conclusions

ERCP is a safe procedure for pediatric patients with low complication rates and rare mortality. We found statistically significant differences in the procedure indications between pediatric age groups, races, and genders. Age ≤ 5 years and male gender were associated with more complicated healthcare courses.

The Clinical Application of Remimazolam Benzenesulfonate Combined with Esketamine Intravenous Anesthesia in Endoscopic Retrograde Cholangiopancreatography

In this project, algorithm-based image processing methods in 3D endoscopic image processing endoscopic retrograde cholangiopancreatography (ERCP) were analyzed. To enhance local information of images, an adaptive histogram equalization method with limited contrast is introduced. The influences of the algorithm on 3D endoscopic image peak signal-to-noise ratio (PSNR), image discrete information entropy (DE), and average mean brightness error (AMBE) of images before and after the optimization before were compared. A total of 92 patients receiving ERCP at Yuhuangding Hospital between December 2019 and December 2021 were selected and divided into the control group (fentanyl+propofol) and the observation group (remimazolam benzenesulfonate+esketamine). Mean arterial pressure heart rate (HR), oxygen saturation (SpO2), and respiratory rate (RR) of the patients at each time point including the entry into the operation room (T0), 2 minutes after the beginning of medication (T1), after endoscopy (T2), endoscopy withdrawal (T3), and postoperative awakening (T4) were recorded. The comparison of MAP between T1, T2, T3, and T4 and T0 among patients in the observation group and the control group showed statistical differences (P < 0.05). Besides, HR and RR at T4 in the observation group were obviously higher than those in the control group (P < 0.05). The comparison of SpO2 at T3 and T4 and that at T0 both showed statistical differences (P < 0.05). Awakening time and VAS scores in the observation group were obviously lower than those in the control group (P < 0.05). The incidence of bradycardia, nausea, vomiting, and chill in the observation group was all lower than that in the control group (P < 0.05). The results indicated that an effective endoscopic image processing method was established based on an image enhancement algorithm, and the combination of remimazolam benzenesulfonate and esketamine showed high safety and efficacy in ERCP.

Systematic review and meta-analysis of the incidence rates of adverse events after digestive endoscopy in children

BACKGROUND

With the widespread use of digestive endoscopy in children, a variety of adverse events (AEs) have occurred after digestive endoscopy. However, there are notable differences in the incidence of adverse reactions in digestive endoscopy in children at present, which makes it difficult to assess the safety of digestive endoscopy in children.

METHODS

Studies related to digestive endoscopy in children were screened from January 2005 to October 2021 from PubMed, Web of Science, Spring, CNKI, and Science Direct databases. RevMan5.3 and Stata were employed to carry out meta-analysis on the incidence of adverse respiratory events, myoclonus, abdominal pain, fever, bleeding, chest pain, sore throat, vomiting, and delayed capsule discharge after digestive endoscopy in children. The article quality was evaluated by the Agency for Healthcare Research and Quality (AHRQ). The chi-square test and I² were adopted to test literature heterogeneity, and the article publication bias was assessed by displaying an inverted funnel plot as a funnel plot.

RESULTS

In all, 15 articles were included, involving a total of 27,770 children. In all, 15 articles were included, involving a total of 27,770 children. The risk ratio (RR) value of adverse respiratory events after digestive endoscopy in children was 1.31 [95% confidence interval (CI): 1.17 to 1.47, P<0.00001]; the odds ratio (OR) value of the incidence of myoclonus was 1.21 (95% CI: 1.01 to 1.46, P=0.04); the incidence of abdominal pain was 1.18 (95% CI: 1.11 to 1.27, P<0.00001); the incidence of fever was 1.09 (95% CI: 1.06 to 1.12, P<0.00001); the incidence of bleeding was 1.24 (95% CI: 0.94 to 1.64, P=0.13); the incidence of chest pain was 1.06 (95% CI: 1.03 to 1.09, P<0.0001); incidence of sore throat was 1.11 (95% CI: 1.05 to 1.18, P=0.0004); incidence of vomiting was 1.13 (95% CI: 1.06 to 1.21, P=0.0001); and the incidence of delayed capsule expulsion was 1.18 (95% CI: 1.00 to 1.40, P=0.05).

DISCUSSION

The incidence of AEs after digestive endoscopy in children was low, which can be used in the diagnosis and therapy of digestive system diseases in children.

Safety and efficacy of endoscopic ultrasound as a diagnostic and therapeutic tool in pediatric patients: a multicenter study

BACKGROUND

Despite the well-established diagnostic and therapeutic applications of endoscopic ultrasound (EUS) in adults, data about its use in children are limited. In this study, we tried to assess the feasibility, safety, and clinical impact of EUS in pediatric patients.

METHODS

Data of pediatric patients (<18 years) referred for EUS over a 3-year period to the endoscopy units of four Egyptian tertiary centers were retrospectively analyzed. Significant impact was defined as a new diagnosis or treatment attributed to the EUS procedure.

RESULTS

Twenty-four diagnostic and five therapeutic EUS procedures were conducted in 29 children with a median age of 9 years. Indications for EUS included assessment of solid pancreatic mass (n = 3), pancreatic cyst (n = 2), suspected chronic pancreatitis (n = 9), pancreatic pseudocyst (PPC) (n = 5), recurrent hypoglycemia (n = 1), bile duct mass (n = 1), subepithelial lesion (esophageal, duodenal or anorectal) (n = 4), mediastinal mass (n = 1), pelvic mass (n = 3), and mass at splenic hilum (n = 1). Therapeutically, five patients underwent cystogastrostomy for symptomatic PPC with 100% technical and clinical success. EUS was able to diagnose 21 out of the other 24 patients. EUS-guided tissue acquisition was performed in 11 patients with definitive histopathological diagnosis in 10 patients (91%). There was no procedure-related major complication, while minor complications occurred in two cases (transient pain in one case, temporary fever, and vomiting in two cases).

CONCLUSION

Standard linear EUS equipment and accessories can be used safely and effectively in selected pediatric patients for diagnostic and therapeutic purposes.