IntroductionEndoscopic retrograde cholangiopancreatography

(ERCP) is a well-known diagnostic and therapeutic tool for pancreaticobiliary diseases in the adult population. While there are many reports of success and complication rates for the adult population, there is a limited amount of data on ERCP in the pediatric population.

Most ERCP in children is performed by trained endoscopists at tertiary or quaternary referral centers from where most studies have originated.

Several recent studies have shown ERCP to be safe and feasible in children ; however, they have included small numbers of patients potentially inflating its safety and efficacy in children.

The main indications for ERCP in children are biliary or pancreatic and include biliary obstruction, anatomic anomaly and bile leak.

Severe complications include pancreatitis, intestinal tract perforation and bleeding. Reported complication rates of pediatric ERCP are variable (from 4% to 13.5%), with most reporting few to no severe complications.

To date, there has been only one study examining pediatric ERCP in a community hospital setting where it was performed by a general surgeon trained in pediatric endoscopy. It evaluated 26 patients over a 5-year period and found no significant differences in success and complication rates as compared to published series (Paris et al., 2010).

Conclusions

DiscussionThis retrospective chart review allowed us to evaluate trends

in the indications for ERCP, therapeutic interventions, complications and outcomes at our institution.

We found ERCP was largely successful (92%) with a moderate rate of complications (14%), which is similar to the most recent study by Paris et al. (2010). Complications comprised mostly of post-ERCP pancreatitis, which may be explained by the large proportion of therapeutic ERCPs performed in our series, as also suggested by Cheng et al. (2005).

Our findings are limited by the small sample size.

Our study represents the largest published study of ERCPs performed in a pediatric community hospital.

TABLE 1. Sample Characteristics

TABLE 3. Final Primary Diagnoses by Category with Quantity of Therapeutic Intervention Performed for Each ERCP

FIGURE 1. Rate of Therapeutic ERCPs and Incidence of Post-ERCP Pancreatitis in Published Pediatric ERCP Series

AcknowledgementsSpecial thanks go to all of our endoscopists, especially Dr. Samir Patel; the Pediatric Gastroenterology Office; Eileen Hanno of Medical Records; and Joanne Joslyn and M. Terry Donley of the Pediatric Residency Program Office.

MethodsStudy Design: Retrospective chart review

CategoryNumber of ERCPs

(%)

Total patientsTotal ERCPs

Age Group (years) < 1 1 – 3 4 – 12 13 – 17

Gender Male Female

Anesthesia Type Conscious sedation Deep sedation MAC General Endotracheal Other

4550

0 (0)2 (4)7 (14)

41 (82)

16 (32)34 (68)

29 (58)0 (0)7 (14)

13 (26)1 (2)

IndicationsNumber of ERCPs (%)

Biliary Suspected choledocholithiasis Suspected sclerosing cholangitis Suspected choledochal cyst Suspected bile leak after trauma to the biliary tree Suspected biliary stricture Evaluation of biliary colic or jaundice without specific features of above pathologic categories

Pancreatic Evaluation of acute pancreatitis

44 (88)34 (68)5 (10)2 (4)4 (8)1 (2)2 (4)

3 (6)

TABLE 2. Indications for ERCPs by Major Category

StudyTotal

patients (n)

Total ERCPs

(n)

Success rate (%)

Complication rate

(overall %)

Cheng et al., 2005 245 329 97.9 9.7

Dua et al., 2008 185 185 98 1.6

Green et al., 2007 19 26 89.5 0

Paris et al., 2010 29 38 97 13.5

Varadarjulu et al., 2004 116 163 97.5 2.5

Vegting et al., 2008 61 99 71* 4

Present study 42 47 92 14

TABLE 4. Comparisons of Pediatric ERCP Series

*In children over the age of 1 year, success rate was 96%.

ResultsFINAL 1° DIAGNOSIS N (%)

Therapeutic Intervention (n)

SS BS/P SP MPS

Biliary Cholelithiasis w/o choledocholithiasis Choledocholithiasis w/ cholecystitis w/ significant ampullary stenosis w/ choledochal cyst Fractured ampulla c/w passed stone Primary Sclerosing Cholangitis Choledochal cyst Biliary trauma w/ bile leak w/o bile leak Hydrops of gallbladder Nonspecific hepatic disease (concurrent)

Pancreatic Acute pancreatitis (concurrent) Chronic pancreatitis (concurrent)

Normal ERCP

1 (2)36 (72)15 (30)

2 (4)1 (2)1 (2)2 (4)3 (6)4 (8)3 (6)1 (2)1 (2)3 (6)

5 (10)1 (2)

1 (2)

11615

1

11

41

11516

11

3

12

31

1

11

1

1

1

SS, stone or sludge removal; BS/P, biliary sphincterotomy/papillotomy; SP, stent placement; MPS, minor papilla sphincterotomy

Specific Aims Describe the demographic and clinical features of

children who have undergone ERCP at our institution

Evaluate the safety of this procedure in children

Identify any complications of ERCP that occurred

Sample: Any pediatric patient, aged 1 year to 17 years 11 months, who underwent ERCP at Advocate Hope Children’s Hospital / Christ Medical Center from January 1999 - March 2011

Study Procedure: Internal review board approval was obtained prior to chart reviews. Charts were reviewed using a consistent data retrieval form.

MethodsDefinitions:

Success was defined as:

Ability to establish a diagnosis

Completion of the appropriate intervention during the procedure (if applicable)

Ability to complete the ERCP procedure

Complications were categorized as related to: anesthesia (i.e., allergy to a sedative), the procedure (i.e., bleeding), and post-procedure events (i.e., pancreatitis).

All procedures were performed by trained endoscopists of the Adult Gastroenterology Department and took place in the hospital’s Gastroenterology Laboratory.

A standard side-viewing duodenoscope was used in almost all cases (Pentax ED 3270k video endoscope, outer diameter 10.8 mm, working channel 3.8mm).

ERCP Procedure Characteristics:

ERCP in the Pediatric Community Hospital Patricia M. Notario, MD*; Tennille N. Webb, MD*; Denise B. Angst, PhD, RN†;

Rajeev Nagpal, MD§

*Department of Pediatrics, †Advocate Center for Pediatric Research, §Department of Pediatric Gastroenterology

Advocate Hope Children’s Hospital, Oak Lawn, IL, USA

Results

Our findings indicate that endoscopists in a community hospital who are trained in pediatric ERCP can successfully and safely perform this procedure.

As the complexity of children seen at community settings increases, large community hospitals will become increasingly important resources for the performance of advanced procedures like ERCP previously done at large academic tertiary and quaternary referral hospitals.

This retrospective chart review allowed us to evaluate trends

Results