Endoscopic cyst gastrostomy for traumatic pancreatic pseudocysts in children: a case series

Pancreatic Cystic Lesions in Children: A Comprehensive Scoping Review

OBJECTIVE

Pediatric pancreatic cystic lesions (PPCLs) are uncommon and differ from adult pancreatic cystic lesions. Literature is limited on the etiologies, evaluation, and management of PPCL. A multidisciplinary working group formed to provide a comprehensive description of PPCL and recommend best available evidence-based evaluation and management.

MATERIALS AND METHODS

The PPCL working group performed a scoping review by 2 methods: 1) a targeted literature review to describe PPCL and 2) a systematic literature review for management recommendations for PPCL. The systematic review was completed using a 2-stage sifting approach: title and abstract screening followed by a full text review.

RESULTS

One hundred thirty-one studies were included in the systematic review and an additional 20 were included in the targeted search to complete a comprehensive list of PPCL. Five neoplastic PPCL and 10 nonneoplastic PPCL were identified, and prevalence of different cystic lesions differs widely in adults and children. Recommendations on evaluation and management of PPCL are presented based on best available evidence.

CONCLUSIONS

We present a comprehensive review and evidence-based management recommendations with management algorithms for pediatric pancreatic cystic lesions. Given the rarity of many of these entities, this review also highlights many aspects of PPCL, which are not adequately described in the current literature.

Duct-related complications of pediatric post-traumatic pancreatitis: A case report from Syria

INTRODUCTION

Pancreatic trauma is a rare type of abdominal injury, representing only 0.3 % of pediatric trauma cases. This condition may progress to chronic pancreatitis and result in multiple complications following damage to the pancreatic duct.

PRESENTATION OF CASE

A 5-year-old boy presented to the hospital with abdominal pain and had a history of chronic pancreatitis following a bicycle handlebar accident one year ago. Ultrasound screening revealed the presence of abdominal ascites which was treated conservatively. Two months post-treatment, the patient developed a pseudocyst in the head of the pancreas and a right-sided pleural effusion that was treated by inserting a plastic stent into the pancreatic duct through endoscopic retrograde cholangiopancreatography (ERCP). This caused inflammation of the pseudocyst, which was eventually drained to the stomach using endoscopy. No recurrence was observed after removing the stents four weeks later.

DISCUSSION

Invasive techniques like ERCP are necessary for some cases of pancreatic fistulas that do not respond well to conservative treatment.

CONCLUSION

ERCP is an effective way to diagnose and treat several duct-related complications of traumatic pancreatitis. Although ideal management of such rare conditions remains highly debatable, non-invasive strategies are preferable for pediatric patients.

Recent progress and current status of pancreatobiliary interventional endoscopic ultrasound in children

In recent years, the usefulness of endoscopic ultrasound (EUS) has been recognized in children. A dedicated pediatric EUS scope has not been developed; in our experience, however, an adult EUS scope can be used. The American Society for Gastrointestinal Endoscopy Technical Committee status assessment report on pediatric endoscopy equipment provides some guidance on the feasibility of EUS according to body size. Careful monitoring is required, keeping in mind potential adverse events such as cervical esophageal perforation and unstable breathing due to tracheal compression. Most devices designed for interventional pancreatobiliary endoscopy are also available for children. Sedation or intubated general anesthesia (GA) is mandatory when performing interventional EUS (I-EUS). I-EUS for children is generally performed using GA in the operating room, but sedation in the endoscopy room is also possible under appropriate monitoring by pediatricians. I-EUS in the operating room is sometimes difficult for endoscopists to perform because of the unsuitable fluoroscopic imaging and the lack of familiar equipment and staff. Compared to GA, sedation in the endoscopy room facilitates easier and quicker repetition of procedures when necessary. Adult pancreatobiliary endoscopists perform most I-EUS procedures in the pediatric population because most pediatric endoscopists have few opportunities to perform EUS-related procedures and thus have difficulty maintaining their skills. To popularize I-EUS techniques for children, it will be necessary to establish a training program for developing pediatric endoscopists.

Evolving Endoscopic Approaches to Pancreatic Pseudocysts and Walled-Off Necrosis: Case Series and Review of Evidence

Imaging followed by endoscopic ultrasound (EUS)-guided therapy has become the preferred modality for treating pancreatic pseudocysts over surgical or radiological interventions. However, there continues to be a lack of consensus regarding the utility of endoscopic retrograde cholangiopancreatography (ERCP) before and after cyst drainage. We describe 4 cases of large pancreatic pseudocyst causing extrinsic biliary obstruction treated successfully with endoscopic cystogastrostomy decompression using a lumen-apposing self-expandable metal stent (LAMS) without ERCP. Endoscopic cystogastrostomy with LAMS was successful in all cases; none required ERCP. As endoscopic therapeutic systems continue to evolve, ERCP is becoming less essential to improve outcomes in patients with extrinsic biliary obstruction by pseudocysts and walled-off necrosis.

Outcomes of Endoscopic Drainage in Children with Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis

PURPOSE

Endoscopic drainage is an established treatment modality for adult patients with pancreatic fluid collections (PFCs). Available data regarding the efficacy and safety of endoscopic drainage in pediatric patients are limited. In this systematic review and meta-analysis, we aimed to analyze the outcomes of endoscopic drainage in children with PFCs.

METHODS

A literature search was performed in Embase, PubMed, and Google Scholar for studies on the outcomes of endoscopic drainage with or without endoscopic ultrasonography (EUS) guidance in pediatric patients with PFCs from inception to May 2021. The study's primary objective was clinical success, defined as resolution of PFCs. The secondary outcomes included technical success, adverse events, and recurrence rates.

RESULTS

Fourteen studies (187 children, 70.3% male) were included in this review. The subtypes of fluid collection included pseudocysts (60.3%) and walled-off necrosis (39.7%). The pooled technical success rates in studies where drainage of PFCs were performed with and without EUS guidance were 95.3% (95% confidence interval [CI], 89.6-98%; I 2=0) and 93.9% (95% CI, 82.6-98%; I 2=0), respectively. The pooled clinical success after one and two endoscopic interventions were 88.7% (95% CI, 82.7-92.9%; I 2=0) and 92.3% (95% CI, 87.4-95.4%; I 2=0), respectively. The pooled rate of major adverse events was 6.3% (95% CI, 3.3-11.4%; I 2=0). The pooled rate of recurrent PFCs after endoscopic drainage was 10.4% (95% CI, 6.1-17.1%; I 2=0).

CONCLUSION

Endoscopic drainage is safe and effective in children with PFCs. However, future studies are required to compare endoscopic and EUS-guided drainage of PFCs in children.

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.