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Endoscopic Retrograde Cholangiopancreatography in Children:A Surgeons Perspective

By Pascale Prasil, Jean-Martin Laberge, Alan Barkun, and Helene Flageole

Montreal, Quebec

Purpose:The aim of this study was to review the indications,

success rate, and complications of endoscopic retrograde

cholangiopancreatography (ERCP) in the pediatric age

group.

Methods: From 1990 to 1999, 21 ERCP procedures were

attempted in 20 patients. They consisted of 8 boys and 12

girls whose age ranged from 4 to 17 years (mean,11.3years).

Fourteen were performed under deep sedation (mean age,

12.8 years), and 7 were done under general anesthesia

(mean age, 7.6 years). All ERCP procedures were performed

by experienced adult endoscopists.

Results:The indication for ERCP was biliary in 15 patients.

Eleven had suspected choledocholithiasis by either ultra-

sound scan, intraoperative cholangiogram or magnetic res-

onance imaging (MRI). In 6 cases, the ERCP was done for

pancreatic pathology. In 11 patients, the ERCP was diagnos-

tic only, and in 10 a therapeutic procedure was done. The

overall success rate was 90.5%. Post-ERCP complications

consisted of 6 episodes of pancreatitis (28.5%), 4 of which

followed a therapeutic procedure, and 1 episode of bleeding.

Pancreatitis resolved 2 to 6 days post-ERCP. The patients

underwent follow-up between 2 and 56 months after the

ERCP (mean, 11 months).

Conclusions: The authors conclude that even in experi-

enced hands, ERCP in the pediatric population has a much

higher complication rate than in adults (33.3%). We rec-

ommend that very specific indications be met before sub-

jecting a pediatric patient to an endoscopic retrogr ade

cholangiopancreatography.

J Pediatr Surg 36:733-735. Copyright 2001 by W.B.

Saunders Company.

INDEX WORDS: Endoscopic retrograde cholangiopancre-

atography, complications.

ENDOSCOPIC retrograde cholangiopancreatography

(ERCP) has been used increasingly in the pediatric

population over the last 10 years both as a diagnostic and

therapeutic modality. Several small and very few larger

series have been published on ERCP in children. They

report success and complication rates comparable with

those quoted in the adult literature.1-7 After encountering

several cases of pancreatitis after ERCP, some that were

done for suspected rather then proven common bile duct

(CBD) stones, we reviewed the experience with ERCP at

the Montreal Childrens Hospital (MCH) to examine our

indications, success rate, and complications in compari-

son with those of other series, and to determine whether

our indications should be revised.

MATERIALS AND METHODS

We reviewed retrospectively the charts of all patients who underwent

an ERCP from 1990 to 1999. Twenty-one ERCP procedures wereundertaken in 20 patients, comprising 8 boys and 12 girls whose ages

ranged from 4 to 17 years (mean, 11.3 years). The indications, results,

and complications were noted as well as the type of anesthesia used.

The latter was decided according to the age of the patient and expected

cooperation. The 7 youngest patients (mean age, 7.6 years) were treated

under general anesthesia in the interventional radiology suite with the

assistance of a pediatric anesthetist, whereas the 14 older teenagers

(mean age, 12.8 years) were given sedation. All ERCP procedures,

whether diagnostic or therapeutic, were performed by a very experi-

enced adult endoscopist using an adult gastroduodenoscope. In the

complications, pancreatitis was defined as abdominal pain post-ERCP

associated with any elevation of the pancreatic enzymes (amylase and

lipase).

RESULTS

The two main indications for ERCP were biliary

pathology in 15 cases and pancreatic pathology in 6cases. In the biliary group, 11 patients had suspected or

proven common bile duct (CBD) stones, and 3 patients

had unexplained biliary tract dilatation by either ultra-

sound scan, magnetic resonance imaging (MRI), or in-

traoperative cholangiogram. The 15th patient had the

examination done to rule out sclerosing cholangitis. The

findings at ERCP in this biliary pathology group were 9

common bile duct stones, 3 normal examinations, 1 CBD

stricture, 1 choledochal cyst, and 1 patient in whom the

CBD could not be cannulated. For the 9 patients with

From the Division of General Pediatric Surgery, Montreal Chil-drens Hospital, McGill University Health Center, Montreal, Quebec,

Canada.

Presented at the 32nd Annual Meeting of the Canadian Association

of Paediatric Surgeons, Chateau Montebello, Quebec, Canada, Sep-

tember 15-18, 2000.

Address reprint requests to Helene Flageole, MD, FRCS(C), FACS,

Montreal Childrens Hospital, 2300 Tupper St, Room C-1129, Mon-

treal, Quebec, Canada H3H 1P3.

Copyright 2001 by W.B. Saunders Company

0022-3468/01/3605-0014$35.00/0

doi:10.1053/jpsu.2001.22948

733Journal of Pediatric Surgery, Vol 36, No 5 (May), 2001: pp 733-735

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CBD stones, 8 sphincterotomies with stone extraction

were done, and 1 underwent partial papillotomy without

stone extraction. The patient with the CBD stricture had

a sphincterotomy with placement of a stent in the CBD.

Overall, 5 ERCP procedures were diagnostic and 10

therapeutic in this group with an overall success rate

(defined as ability to complete the diagnostic or thera-

peutic procedure) of 86.7%. Seven patients in this group

suffered complications post-ERCP (47%). Six of them

had pancreatitis as evidenced by abdominal pain and

biochemical abnormalities, namely elevated serum amy-

lase and lipase levels. Of these, 4 children had undergone

a sphincterotomy. One other patient had a simple diag-

nostic ERCP, the results of which were normal, and in

the sixth patient there was inability to cannulate the

CBD. Two of the episodes of pancreatitis were severe

enough to require hospital stays of 8 and 9 days, whereas

the other 4 episodes were rather mild with complete

resolution of the symptoms in 1 to 3 days. The othercomplication in the biliary pathology group consisted of

1 episode of bleeding. The patient returned to hospital 24

hours after ERCP with melena and hypotension. He

required transfusion of 2 units of packed red blood cells,

and the bleeding ceased spontaneously.

There were 6 ERCP procedures performed for pancre-

atic pathology in 5 patients with either recurrent or

chronic pancreatitis. One child underwent 2 ERCP pro-

cedures several years apart. All procedures were diag-

nostic only, and the success rate in this group was 100%.

These showed 3 normal findings and 3 pancreatic duct

anomalies, one of which was amenable to surgical ther-

apy. There were no complications in this group.The follow-up after ERCP ranged from 2 to 56 months

(mean, 11 months). The results are summarized in Table

1. None of the patients had long-term sequelae from

ERCP, regardless of whether they had early complica-

tions.

DISCUSSION

ERCP is being used with increasing frequency in the

pediatric and even the neonatal population. In biliary

disorders, it can be both diagnostic and therapeutic,

especially in cases of choledocholithiasis. However, in

cases in which the need for therapeutic intervention is

uncertain, magnetic resonance cholangiopancreatogra-

phy (MRCP) is being used increasingly as a diagnostic

modality prior to ERCP.8,9 ERCP also is very useful in

defining the anatomy of pancreatic duct abnormalities,

where the results could dictate the therapeutic options

offered to the patient. Examples would include the mul-

tiple strictures and dilatations sometimes seen in chronic

pancreatitis and pancreas divisum causing recurrent pan-

creatitis, conditions amenable to surgical correction.

Nonetheless, ERCP is not without risks, especially in

young children and infants. As do others, we feel that in

this group of patients, a general anesthetic is the safest

method to protect the airway and ensure an immobile pa-

tient.6,7,10 In our series, 35% (7 of 20) of patients be-

longed to this category. There are reports of ERCP being

performed in the neonate and young child under sedation,

but this approach has yet to gain wide acceptance.1 In

such a context, the indication for ERCP should be strong.

It should not be used as a screening test for conditions

such as unexplained abdominal pain, in which the like-lihood of finding significant pathology is minimal.3

When examining complications from ERCP, the ref-

erence point clearly is the adult literature. Even in adults,

the morbidity and mortality rates after ERCP are appre-

ciable. A prospective multicenter study by Loperfido et

al11 conducted on 2,769 consecutive patients in 9 differ-

ent centers makes that point. They reported major com-

plications in 4% of patients, with pancreatitis, cholangi-

tis, and hemorrhage being the most frequent. There were

1.38% major complications and 0.21% deaths in the

diagnostic ERCP group, whereas patients in the thera-

peutic group suffered 5.4% complications and 0.49%

mortality rate. Centers performing fewer than 200 ERCPper year and the performance of a partial papillotomy,

sometimes referred to as a pre-cut procedure, were

identified as independent risk factors for complications.

In the pediatric population, the relatively low volume

of cases definitely is an issue. This problem is minimized

in our institution by having a very limited number of

very experienced adult endoscopists perform the proce-

dures in children.12 These selected individuals perform a

large number of adult ERCP procedures each year, but

their level of comfort with children undoubtedly varies

because we only have a few cases each year. Even in

these experienced hands, our complication rate was

33.3%, 86% of which were episodes of pancreatitis. Onethird of these episodes were severe enough to require

hospitalization for more than 1 week. Half of patients

undergoing a therapeutic ERCP procedure suffered from

complications. Our rate of complications seems higher

than that of most reported series despite all the measures

taken to minimize the risks as described above. This

could be partially explained by the fact that we were very

rigorous in reporting them. Each patient had routine

biochemical testing the day after ERCP, and any eleva-

Table 1. Summary of Results

Indication

Biliary Pathology

(n 15)

Pancreatic Pathology

(n 6)

Diagnostic ERCP 5 6

Therapeutic ERCP 10 0

Success rate 86.7% 100%

Pancreatitis post-ERCP 6 (40%) 0%

Bleeding post-ERCP 1 (6.6%) 0%

734 PRASIL ET AL

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tion in amylase and lipase levels were counted as pan-

creatitis. Four of our 6 patients had mild pancreatitis,

which could perhaps have gone unnoticed in other cir-

cumstances.

Nonetheless, the complication rate from ERCP is sig-

nificantly higher in our population than that reported in

adults. We therefore recommend that strict selection

criteria be met before subjecting a pediatric patient to an

ERCP, especially when biliary lithiasis is the indication.

Suspicion of CBD stones on the basis of CBD dilatation

or elevated enzymes should not be an indication for

preoperative ERCP. In such cases, we recommend pro-

ceeding first with laparoscopic cholecystectomy and in-

traoperative cholangiogram. ERCP follows if CBD

stones persist despite intraoperative flushing.

ERCP remains an essential diagnostic tool in children

with unexplained recurrent pancreatitis and in those with

biliary tract pathology such as Carolis disease, scleros-

ing cholangitis, and choledochal cyst when less invasive

imaging modalities fail to provide a diagnosis.

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735ERCP: A SURGEONS PERSPECTIVE