Landscape of Pediatric Endoscopic Ultrasound in a United States Tertiary Care Medical Center

Abstract

Background: Endoscopic ultrasound (EUS) is a commonly used radiationsparing procedure in adult patients for diagnostic sampling of gastrointestinal lesions and fluid collections, gastric variceal hemostasis, biliary/pancreatic duct drainage, and endo-surgical interventions. Integration of EUS in pediatrics is still in its infancy with limited data regarding its use. The present study analyzes utilization, diagnostic and therapeutic roles of pediatric EUS and evolution in these parameters over time. Methods: Records of patients 18 years or younger from 2009 to 2020 at our tertiary pediatric care center were retrospectively identified. Patient demographics, symptoms, laboratory studies, EUS indications and interventions, and clinical outcomes of the procedures were analyzed. Statistical analysis was performed using Student t-test, Pearson's chisquare and Fisher exact tests. Results: 306 EUS procedures were performed during the study period, for 279 pediatric patients. These included 287 (93.8%) upper EUS and 19 (6.2%) lower EUS. Two hundred and twenty-nine procedures were diagnostic (74.8%) and 77 were therapeutic (25.2%). EUS indications included evaluation and therapy of the pancreaticobiliary region (231, 75.5%), subepithelial or regional lesion (54, 17.8%), celiac plexus block (19, 6.2%) and hemostasis (14, 4.5%). Diagnostic sampling was performed in 52 of these EUS procedures, with a 96.2% diagnostic yield. 98.7% of therapeutic procedures were technically successful and there were no associated adverse events. Conclusion:The diagnostic and therapeutic role for EUS in adults has expanded dramatically, however the role of EUS in pediatrics is not welldefined. In this, the largest pediatric EUS study to date, our data support the safety and utility of diagnostic and therapeutic EUS in pediatrics.

Endotherapy in pediatric pancreatitis

“…Watchful waiting is recommended for large collections, but when spontaneous resolution is not anticipated EUS-guided drainage has become first line across many pediatric centers and often saves children from more invasive percutaneous approaches by general surgery or interventional radiology [11]. Reported technical success ranges from 95% to 100% [11,24 ▪▪ ,25,26 ▪ ]. Adverse event rates are low but not insignificant.…”

“…Given its invasive nature and need for sedation or general anesthesia in children, it is typically reserved for scenarios in which conventional imaging (transabdominal ultrasound, CT or MRCP) have not provided adequate information or in situations where both diagnosis and therapy are anticipated in the same procedure. Some centers have seen increased therapeutic use in the last several years [24 ▪▪ ]. The most common pancreatic indication for endoscopic ultrasound (EUS) guided therapy is for drainage of pancreatic fluid collections or walled off necrosis.…”

Endoscopic Advancements in Pediatric Pancreatitis

“…Endoscopic ultrasonography allows for highly detailed transgastric and transduodenal sonographic images of the pancreas and peripancreatic anatomy through an echoendoscope and can be safely and effectively performed in children ( 3 , 6 , 12 , 13 ). EUS has been established in adults since the 1980s and is sensitive for evaluating changes in the pancreas that reflect CP, including specific parenchymal and ductal changes.…”

“…Metal and plastic stents have been used in children successfully, along with lumen apposing metal stents ( 13 , 32 – 34 ). EUS guided celiac plexus blockade in patients with CP and debilitating pain has been used successfully in adult and pediatric patients ( 6 , 35 – 37 ). Pediatric patients with conventional or post-surgical anatomy with dilation of the pancreatic duct but the inability to cannulate the duct via ERCP are candidates for pancreatic duct rendezvous via EUS ( 38 ).…”

“…Diagnostic EUS presents risk rates similar to upper endoscopy, while interventional EUS presents higher risks of infection, bleeding and perforation. The failure rate for complex procedures, such as pancreatic rendezvous, can approach 30% ( 6 , 39 , 40 ).…”