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Su1757 Pediatric Gastroenterologists Performing ERCP: a US Survey
Abstracts
helpfulness as determined by physician questionnaire. Of note, 21 patients (26.7%) who underwent ERCP had pancreatic stones removed with the majority of these patients experiencing improvement in pain (65%) and ARP (61%). Conclusions: Therapeutic ERCP was undertaken in nearly half the patients within the INSPPIRE with ARP and CP and was most helpful when performed to relieve obstruction secondary to pancreatic stones. The effectiveness of ERCP in the setting of recurrent pain, acute recurrent pancreatitis, pseudocyst management, removal of biliary stones and management of jaundice in the INSPPIRE population needs to be further investigated using prospective data collection. On behalf of INSPPIRE Consortium, supported by NIH R21 DK096327, CTSA 2UL1 TR000442-06 and REDCap
Table 1. Procedures performed during ERCP for various indications along with reported helpfulness.
Su1756 Endoscopic Ultrasound (EUS): a Proposed Role in Pediatric Eosinophilic Esophagitis (EoE) Fernando J. Windemuller*1, Evan B. Grossman2, Hanh Vo1, Virginia Anderson3, Raavi Gupta3, Steven M. Schwarz1, Simon S. Rabinowitz1 1 Pediatric Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY; 2Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY; 3 Pathology, SUNY Downstate Medical Center, Brooklyn, NY Introduction: Previously, EUS has documented increased esophageal (esph) total wall thickening (TWT) in Pediatric Eosinophilic Esophagitis (EoE) compared to children with gastroesophageal reflux (GER) and decreased TWT in adults who responded to EoE treatment. This report describes EUS data obtained in a longitudinal study on the evolution of Pediatric EoE . Methods: 18 patients ( M:14, F:4, mean age 10 +/-6y, range 3- 20Y) with known EoE (previous esph biopsy O15 eos/hpf) had 28 EUS exams performed utilizing a 12 or 20mHz ultrasound probe at the mid-esph (nZ27) and distal-esph (nZ28) prior to obtaining esph biopsies at the same sites. Five patients who were studied for suspected EoE were found to have GER. Two EoE patients were found on subsequent endoscopies to have histology consistent with EGID (increased eosinophils in the stomach and duodenum). Results: 4 EoE patients in remission (EoE-R; eos!15/hpf in both biopsies) had EUS, one of whom had previous belonged to the EoE-A group but underwent remission after treatment. The mean TWT obtained in these EoE-R exams was mid-esph Z 2 0.9 mm (range 1.1-3.9mm) and distal-esph was 1.9 0.3 mm (range 1.5 - 2.3mm). One boy who was EoE-A went into histologic remission but maintained and increased TWT. These values were similar to GER. 8 other patients had active disease (EoE-A; O15 eos/hpf in mid and/or distal-esph). EUS in this group revealed mean TWT in the mid-esphZ 2.2 0.5mm (range 1.1-2.6) and in distal-esph Z 2.4 0.6mm (range 1.2-3.1). As shown in adults, effective EoE therapy can decrease eos and TWT. Two children with EoE, later found to have EGID had esph TWT, eos/hpf and clinical responses identical to EoE. Discussion: These results suggest EUS can complement mucosal biopsies in clinical decision making and assessing the progression of EoE.
Su1757 Pediatric Gastroenterologists Performing ERCP: a US Survey David Troendle*1, Douglas S. Fishman4,5, Victor L. Fox3, Bradley a. Barth1,2 1 UT Southwestern Medical Center, Dallas, TX; 2Children’s Medical Center Dallas, Dallas, TX; 3Boston Children’s Hospital, Boston, MA; 4 Texas Children’s Hospital, Houston, TX; 5Baylor College of Medicine, Houston, TX
number, training, and scope of practice of pediatric gastroenterologists (PedGEs) who independently perform this procedure in children. The goal of this survey was to better quantify the training, volume, and scope of practice of PedGEs currently performing ERCP. Methods: With IRB approval, A REDCaps survey was administered to 68 PedGEs who manage endoscopy operations for their academic or private practice according to a national endoscopy register. Centers with PedGEs performing ERCP were queried about initial training, cumulative and annual case volume, scope of practice, continuing medical education (CME), and quality monitoring, all specifically related to ERCP. Results: The survey had a response rate of (32/68) 47% and identified 12 PedGEs who performed ERCP for some or all indications. Four (33%) of these endoscopists had completed a formal adult therapeutic endoscopy fellowship, while the remainder gained experience under the guidance of an experienced adult endoscopist in an informal setting. Three (25%) had performed !100, 2 (17%) had performed between 101-150, and 7 (58%) had performed O150 ERCPs prior to independent practice. Five (42%) have been independently performing ERCP for more than 5 years. Seven (58%) perform greater than 40 ERCPs annually. All but one respondent performed ERCP for all complexity grade 1 and 2 indications and selectively placed prophylactic pancreatic stents to prevent post-ERCP pancreatitis, which is the threshold for independent practice recommended by the American Society for Gastrointestinal Endoscopy (ASGE). Respondents more variably performed grade 3 and 4 ERCPs with most seeking assistance when specialized equipment or advanced techniques were needed. Forms of CME included additional supervision by an experienced adult endoscopist (5, 42%) and either hands-on (3, 25%) or non-hands-on (8, 67%) ERCP coursework. Quality monitoring using an individual database was performed by all but one respondent. Conclusions: Very few PedGEs perform ERCP, most often after training informally under the guidance of an experienced adult endoscopist. Nearly all meet or exceed the practice complexity threshold for independent practice recommended by the ASGE and the majority pursue procedurespecific CME and quality monitoring. Yet, they fall short of commonly recommended training thresholds and annual volume targets. Research is needed to determine what ERCP training and volume thresholds will enable PedGEs to achieve acceptable rates of technical success and clinical improvement with minimal adverse events.
Su1758 Single Balloon Small Bowel Enteroscopy in Children: a Single Center Review of 37 Cases Robert Kramer* Pediatrics, University of Colorado, Aurora, CO Background: Since balloon enteroscopy was initially described in 2001 there have been limited reported series in children, with the majority of these from outside the U. S. and employing double rather than single balloon enteroscopy. Objectives: To describe a relatively large cohort of children undergoing single balloon enteroscopy at a pediatric academic tertiary care center in the U. S. Methods: A total of 37 enteroscopies (both antegrade and retrograde) were performed in 34 children and adolescents (21 male) between November 2007 and December 2013. All procedures were performed by a single pediatric endoscopist, utilizing the Olympus SIF-Q180 enteroscope and single balloon overtube (OD 13.2 mm). An Olympus balloon control unit was used, with a set pressure of 5.4 kPa 2.6 kPa. The Procedures were all performed with fluoroscopic guidance and under general anesthesia. Results: The mean age of the patients was 10.8 years (SD 5.5, range 2.1 to 24 years) with a mean weight of 37.7 kg (SD 20.8, range 11.8 to 77.2 kg). Of the total, 29 procedures (78.4%) were antegrade and 8 were retrograde. A preceding capsule study was performed in 19 (51.4%) and 12 studies (29.7%) were interventional. Endoscopic interventions included polyp removal in 6, attempted removal of retained surgical stents (post liver transplant) in 3, dilation in 2 and endoscopic treatment of bleeding in 1. In 30 studies (81.1%) the procedure was felt to be technically successful in visualizing the targeted area of small bowel, with no significant difference in success rates between antegrade and retrograde procedures (pZ0.143). The mean duration of procedures was 86.2 minutes (SD 31.9, range 46 to 180 min). The average number of advancement cycles was 5.0 (SD 1.6, range 1 to 8) and the estimated depth of insertion beyond the pylorus or ICV was 140.5 cm (SD 64.4, range 0 to 240) respectively. The mean fluoroscopy time, when measured, was 78.8 seconds (SD 27.9, range 48 to 110 seconds). Post-enteroscopy complications were encountered in 3 patients (8.11%): two with abdominal pain, resulting in a negative evaluation in the emergency department (Grade 2) and one with fever in the context of a central line, resulting in admission (Grade 3) but negative cultures. In no patient was there an identified hemorrhage, infection, or perforation. In 17 cases (46.0%) the enteroscopy was felt to have significantly altered or impacted the patient treatment plan. Conclusions: Single balloon enteroscopy can be safely and successfully performed even in small pediatric patients, down to 12 kg. Further study is needed, however, to optimally define the indications for these procedures to maximize their diagnostic yield.
Background: While endoscopic retrograde cholangiopancreatograpy (ERCP) has been shown to be safe and effective in patients of all ages, little is known about
AB286 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
www.giejournal.org
helpfulness as determined by physician questionnaire. Of note, 21 patients (26.7%) who underwent ERCP had pancreatic stones removed with the majority of these patients experiencing improvement in pain (65%) and ARP (61%). Conclusions: Therapeutic ERCP was undertaken in nearly half the patients within the INSPPIRE with ARP and CP and was most helpful when performed to relieve obstruction secondary to pancreatic stones. The effectiveness of ERCP in the setting of recurrent pain, acute recurrent pancreatitis, pseudocyst management, removal of biliary stones and management of jaundice in the INSPPIRE population needs to be further investigated using prospective data collection. On behalf of INSPPIRE Consortium, supported by NIH R21 DK096327, CTSA 2UL1 TR000442-06 and REDCap
Table 1. Procedures performed during ERCP for various indications along with reported helpfulness.
Su1756 Endoscopic Ultrasound (EUS): a Proposed Role in Pediatric Eosinophilic Esophagitis (EoE) Fernando J. Windemuller*1, Evan B. Grossman2, Hanh Vo1, Virginia Anderson3, Raavi Gupta3, Steven M. Schwarz1, Simon S. Rabinowitz1 1 Pediatric Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY; 2Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY; 3 Pathology, SUNY Downstate Medical Center, Brooklyn, NY Introduction: Previously, EUS has documented increased esophageal (esph) total wall thickening (TWT) in Pediatric Eosinophilic Esophagitis (EoE) compared to children with gastroesophageal reflux (GER) and decreased TWT in adults who responded to EoE treatment. This report describes EUS data obtained in a longitudinal study on the evolution of Pediatric EoE . Methods: 18 patients ( M:14, F:4, mean age 10 +/-6y, range 3- 20Y) with known EoE (previous esph biopsy O15 eos/hpf) had 28 EUS exams performed utilizing a 12 or 20mHz ultrasound probe at the mid-esph (nZ27) and distal-esph (nZ28) prior to obtaining esph biopsies at the same sites. Five patients who were studied for suspected EoE were found to have GER. Two EoE patients were found on subsequent endoscopies to have histology consistent with EGID (increased eosinophils in the stomach and duodenum). Results: 4 EoE patients in remission (EoE-R; eos!15/hpf in both biopsies) had EUS, one of whom had previous belonged to the EoE-A group but underwent remission after treatment. The mean TWT obtained in these EoE-R exams was mid-esph Z 2 0.9 mm (range 1.1-3.9mm) and distal-esph was 1.9 0.3 mm (range 1.5 - 2.3mm). One boy who was EoE-A went into histologic remission but maintained and increased TWT. These values were similar to GER. 8 other patients had active disease (EoE-A; O15 eos/hpf in mid and/or distal-esph). EUS in this group revealed mean TWT in the mid-esphZ 2.2 0.5mm (range 1.1-2.6) and in distal-esph Z 2.4 0.6mm (range 1.2-3.1). As shown in adults, effective EoE therapy can decrease eos and TWT. Two children with EoE, later found to have EGID had esph TWT, eos/hpf and clinical responses identical to EoE. Discussion: These results suggest EUS can complement mucosal biopsies in clinical decision making and assessing the progression of EoE.
Su1757 Pediatric Gastroenterologists Performing ERCP: a US Survey David Troendle*1, Douglas S. Fishman4,5, Victor L. Fox3, Bradley a. Barth1,2 1 UT Southwestern Medical Center, Dallas, TX; 2Children’s Medical Center Dallas, Dallas, TX; 3Boston Children’s Hospital, Boston, MA; 4 Texas Children’s Hospital, Houston, TX; 5Baylor College of Medicine, Houston, TX
number, training, and scope of practice of pediatric gastroenterologists (PedGEs) who independently perform this procedure in children. The goal of this survey was to better quantify the training, volume, and scope of practice of PedGEs currently performing ERCP. Methods: With IRB approval, A REDCaps survey was administered to 68 PedGEs who manage endoscopy operations for their academic or private practice according to a national endoscopy register. Centers with PedGEs performing ERCP were queried about initial training, cumulative and annual case volume, scope of practice, continuing medical education (CME), and quality monitoring, all specifically related to ERCP. Results: The survey had a response rate of (32/68) 47% and identified 12 PedGEs who performed ERCP for some or all indications. Four (33%) of these endoscopists had completed a formal adult therapeutic endoscopy fellowship, while the remainder gained experience under the guidance of an experienced adult endoscopist in an informal setting. Three (25%) had performed !100, 2 (17%) had performed between 101-150, and 7 (58%) had performed O150 ERCPs prior to independent practice. Five (42%) have been independently performing ERCP for more than 5 years. Seven (58%) perform greater than 40 ERCPs annually. All but one respondent performed ERCP for all complexity grade 1 and 2 indications and selectively placed prophylactic pancreatic stents to prevent post-ERCP pancreatitis, which is the threshold for independent practice recommended by the American Society for Gastrointestinal Endoscopy (ASGE). Respondents more variably performed grade 3 and 4 ERCPs with most seeking assistance when specialized equipment or advanced techniques were needed. Forms of CME included additional supervision by an experienced adult endoscopist (5, 42%) and either hands-on (3, 25%) or non-hands-on (8, 67%) ERCP coursework. Quality monitoring using an individual database was performed by all but one respondent. Conclusions: Very few PedGEs perform ERCP, most often after training informally under the guidance of an experienced adult endoscopist. Nearly all meet or exceed the practice complexity threshold for independent practice recommended by the ASGE and the majority pursue procedurespecific CME and quality monitoring. Yet, they fall short of commonly recommended training thresholds and annual volume targets. Research is needed to determine what ERCP training and volume thresholds will enable PedGEs to achieve acceptable rates of technical success and clinical improvement with minimal adverse events.
Su1758 Single Balloon Small Bowel Enteroscopy in Children: a Single Center Review of 37 Cases Robert Kramer* Pediatrics, University of Colorado, Aurora, CO Background: Since balloon enteroscopy was initially described in 2001 there have been limited reported series in children, with the majority of these from outside the U. S. and employing double rather than single balloon enteroscopy. Objectives: To describe a relatively large cohort of children undergoing single balloon enteroscopy at a pediatric academic tertiary care center in the U. S. Methods: A total of 37 enteroscopies (both antegrade and retrograde) were performed in 34 children and adolescents (21 male) between November 2007 and December 2013. All procedures were performed by a single pediatric endoscopist, utilizing the Olympus SIF-Q180 enteroscope and single balloon overtube (OD 13.2 mm). An Olympus balloon control unit was used, with a set pressure of 5.4 kPa 2.6 kPa. The Procedures were all performed with fluoroscopic guidance and under general anesthesia. Results: The mean age of the patients was 10.8 years (SD 5.5, range 2.1 to 24 years) with a mean weight of 37.7 kg (SD 20.8, range 11.8 to 77.2 kg). Of the total, 29 procedures (78.4%) were antegrade and 8 were retrograde. A preceding capsule study was performed in 19 (51.4%) and 12 studies (29.7%) were interventional. Endoscopic interventions included polyp removal in 6, attempted removal of retained surgical stents (post liver transplant) in 3, dilation in 2 and endoscopic treatment of bleeding in 1. In 30 studies (81.1%) the procedure was felt to be technically successful in visualizing the targeted area of small bowel, with no significant difference in success rates between antegrade and retrograde procedures (pZ0.143). The mean duration of procedures was 86.2 minutes (SD 31.9, range 46 to 180 min). The average number of advancement cycles was 5.0 (SD 1.6, range 1 to 8) and the estimated depth of insertion beyond the pylorus or ICV was 140.5 cm (SD 64.4, range 0 to 240) respectively. The mean fluoroscopy time, when measured, was 78.8 seconds (SD 27.9, range 48 to 110 seconds). Post-enteroscopy complications were encountered in 3 patients (8.11%): two with abdominal pain, resulting in a negative evaluation in the emergency department (Grade 2) and one with fever in the context of a central line, resulting in admission (Grade 3) but negative cultures. In no patient was there an identified hemorrhage, infection, or perforation. In 17 cases (46.0%) the enteroscopy was felt to have significantly altered or impacted the patient treatment plan. Conclusions: Single balloon enteroscopy can be safely and successfully performed even in small pediatric patients, down to 12 kg. Further study is needed, however, to optimally define the indications for these procedures to maximize their diagnostic yield.
Background: While endoscopic retrograde cholangiopancreatograpy (ERCP) has been shown to be safe and effective in patients of all ages, little is known about
AB286 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
www.giejournal.org