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PCRE en niños, perspectiva de un cirujano

PCRE en niños, perspectiva de un cirujano

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Endoscopic Retrograde Cholangiopancreatography in Children:A Surgeon’s Perspective
By Pascale Prasil, Jean-Martin Laberge, Alan Barkun, and He´le`ne Flageole
Montreal, Quebec 
The aim of this study was to review the indications,success rate, and complications of endoscopic retrogradecholangiopancreatography (ERCP) in the pediatric agegroup.
From 1990 to 1999, 21 ERCP procedures wereattempted in 20 patients. They consisted of 8 boys and 12girlswhoseagerangedfrom4to17years(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 performedby experienced adult endoscopists.
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 forpancreatic pathology. In 11 patients, the ERCP was diagnos-tic only, and in 10 a therapeutic procedure was done. Theoverall success rate was 90.5%. Post-ERCP complicationsconsisted of 6 episodes of pancreatitis (28.5%), 4 of whichfollowed a therapeutic procedure, and 1 episode of bleeding.Pancreatitis resolved 2 to 6 days post-ERCP. The patientsunderwent follow-up between 2 and 56 months after theERCP (mean, 11 months).
The authors conclude that even in experi-enced hands, ERCP in the pediatric population has a muchhigher 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 retrogradecholangiopancreatography.
J Pediatr Surg 36:733-735. Copyright 
2001 by W.B.Saunders Company.
INDEX WORDS: Endoscopic retrograde cholangiopancre-atography, complications.
NDOSCOPIC retrograde cholangiopancreatography(ERCP) has been used increasingly in the pediatricpopulation over the last 10 years both as a diagnostic andtherapeutic modality. Several small and very few largerseries have been published on ERCP in children. Theyreport success and complication rates comparable withthose quoted in the adult literature.
After encounteringseveral cases of pancreatitis after ERCP, some that weredone for suspected rather then proven common bile duct(CBD) stones, we reviewed the experience with ERCP atthe Montreal Children’s Hospital (MCH) to examine ourindications, success rate, and complications in compari-son with those of other series, and to determine whetherour indications should be revised.
We reviewed retrospectively the charts of all patients who underwentan ERCP from 1990 to 1999. Twenty-one ERCP procedures wereundertaken in 20 patients, comprising 8 boys and 12 girls whose agesranged 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 expectedcooperation. The 7 youngest patients (mean age, 7.6 years) were treatedunder general anesthesia in the interventional radiology suite with theassistance 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 thecomplications, pancreatitis was defined as abdominal pain post-ERCPassociated with any elevation of the pancreatic enzymes (amylase andlipase).
The two main indications for ERCP were biliarypathology in 15 cases and pancreatic pathology in 6cases. In the biliary group, 11 patients had suspected orproven common bile duct (CBD) stones, and 3 patientshad unexplained biliary tract dilatation by either ultra-sound scan, magnetic resonance imaging (MRI), or in-traoperative cholangiogram. The 15th patient had theexamination done to rule out sclerosing cholangitis. Thefindings at ERCP in this biliary pathology group were 9common bile duct stones, 3 normal examinations, 1 CBDstricture, 1 choledochal cyst, and 1 patient in whom theCBD could not be cannulated. For the 9 patients with
From the Division of General Pediatric Surgery, Montreal Chil-dren’s Hospital, McGill University Health Center, Montreal, Quebec,Canada.Presented at the 32nd Annual Meeting of the Canadian Associationof Paediatric Surgeons, Chaˆteau Montebello, Quebec, Canada, Sep-tember 15-18, 2000. Address reprint requests to He´le`ne Flageole, MD, FRCS(C), FACS, Montreal Children’s Hospital, 2300 Tupper St, Room C-1129, Mon-treal, Quebec, Canada H3H 1P3.Copyright © 2001 by W.B. Saunders Company0022-3468/01/3605-0014$35.00/0doi:10.1053/jpsu.2001.22948 
Journal of Pediatric Surgery,
Vol 36, No 5 (May), 2001: pp 733-735
CBD stones, 8 sphincterotomies with stone extractionwere done, and 1 underwent partial papillotomy withoutstone extraction. The patient with the CBD stricture hada sphincterotomy with placement of a stent in the CBD.Overall, 5 ERCP procedures were diagnostic and 10therapeutic 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 groupsuffered complications post-ERCP (47%). Six of themhad pancreatitis as evidenced by abdominal pain andbiochemical abnormalities, namely elevated serum amy-lase and lipase levels. Of these, 4 children had undergonea sphincterotomy. One other patient had a simple diag-nostic ERCP, the results of which were normal, and inthe sixth patient there was inability to cannulate theCBD. Two of the episodes of pancreatitis were severeenough to require hospital stays of 8 and 9 days, whereasthe other 4 episodes were rather mild with completeresolution 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 24hours after ERCP with melena and hypotension. Herequired 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 orchronic 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 ductanomalies, 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 Table1. None of the patients had long-term sequelae fromERCP, regardless of whether they had early complica-tions.
ERCP is being used with increasing frequency in thepediatric and even the neonatal population. In biliarydisorders, it can be both diagnostic and therapeutic,especially in cases of choledocholithiasis. However, incases in which the need for therapeutic intervention isuncertain, magnetic resonance cholangiopancreatogra-phy (MRCP) is being used increasingly as a diagnosticmodality prior to ERCP.
ERCP also is very useful indefining the anatomy of pancreatic duct abnormalities,where the results could dictate the therapeutic optionsoffered to the patient. Examples would include the mul-tiple strictures and dilatations sometimes seen in chronicpancreatitis and pancreas divisum causing recurrent pan-creatitis, conditions amenable to surgical correction.Nonetheless, ERCP is not without risks, especially inyoung children and infants. As do others, we feel that inthis group of patients, a general anesthetic is the safestmethod to protect the airway and ensure an immobile pa-tient.
In our series, 35% (7 of 20) of patients be-longed to this category. There are reports of ERCP beingperformed in the neonate and young child under sedation,but this approach has yet to gain wide acceptance.
Insuch a context, the indication for ERCP should be strong.It should not be used as a screening test for conditionssuch as unexplained abdominal pain, in which the like-lihood of finding significant pathology is minimal.
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 etal
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 were1.38% major complications and 0.21% deaths in thediagnostic 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, wereidentified as independent risk factors for complications.In the pediatric population, the relatively low volumeof cases definitely is an issue. This problem is minimizedin our institution by having a very limited number of very experienced adult endoscopists perform the proce-dures in children.
These selected individuals perform alarge number of adult ERCP procedures each year, buttheir level of comfort with children undoubtedly variesbecause we only have a few cases each year. Even inthese experienced hands, our complication rate was33.3%, 86% of which were episodes of pancreatitis. Onethird of these episodes were severe enough to requirehospitalization for more than 1 week. Half of patientsundergoing a therapeutic ERCP procedure suffered fromcomplications. Our rate of complications seems higherthan that of most reported series despite all the measurestaken to minimize the risks as described above. Thiscould be partially explained by the fact that we were veryrigorous in reporting them. Each patient had routinebiochemical testing the day after ERCP, and any eleva-
Table 1. Summary of Results
IndicationBiliary Pathology(n
15)Pancreatic Pathology(n
Diagnostic ERCP 5 6Therapeutic ERCP 10 0Success 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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