Editor: Peter B. Cotton
10. ERCP in children
ERCP has substantially influenced the evaluation and treatment of adult patients with suspected pancreatic and biliary disease.
The first reports of ERCP in infants and children were chiefly from adult gastroenterologists experienced with such techniques.
The growth in number and availability of skilled endoscopists has resulted in more frequent performance of ERCP in children.
Moreover, the acquired ability to perform therapeutic endoscopic procedures is also applicable to children and adolescents.
Techniques such as endoscopic sphincterotomy, biliary drainage, extraction of common bile duct and pancreatic duct stones,
implantation of endoprostheses, and drainage of pancreatic pseudocysts are beginning to be used in children with an overall
success rate similar to that reported for adult patients. In this chapter we define the technique, the indications, the complications,
and the diagnostic and therapeutic applications of ERCP in children.
Endoscopic retrograde cholangiopancreatography (ERCP) is the most demanding endoscopic procedure in children. It is the most
sensitive and specific technique in the evaluation and treatment of children with suspected disorders of the pancreas and
the biliary tract. The disadvantage is that it is an invasive procedure that frequently needs general anesthesia. The use
of this technique in children has been limited. This may be due to the relative low incidence of diseases, low incidence of
clinical suspicion, limited availability of pediatric duodenoscopes, lack of pediatric gastroenterologists well-trained in
ERCP due to little exposure to the procedure, impression that ERCP in children is technically difficult to accomplish, difficulty
in the effective evaluation of the therapeutic result, and because the indications and safety of ERCP in children have not
been well defined. Since the procedure is frequently performed by experienced adult endoscopists, it is important to have
a close working collaboration between them and pediatric gastroenterologists.
Sedation for ERCP in children
The preparation and sedation of a child undergoing ERCP is similar to that used for upper gastrointestinal endoscopy. Since
young children and some adolescents are unable to fully cooperate with procedures under conscious sedation, a state of deep
sedation from which the patient is not easily aroused is often required. The endoscopist must choose between conscious sedation
and general anesthesia after considering the pertinent risks and taking into account personal skill and experience, expected
complexity of the procedure, and lastly, cost.
Most children can be adequately sedated with a combination of meperidine (24 mg/kg, maximum 100 mg) and diazepam (0.10.3 mg/kg, maximum 15 mg) or midazolam (0.10.3 mg/kg, maximum 15 mg). To obtain adequate sedation, children frequently require much higher doses of midazolam on a milligram per kilogram basis
than adults. Post-procedure monitoring is the same as for other endoscopic procedures requiring sedation.
There are no data to guide antibiotic prophylaxis for ERCP in children. In our experience routine antibiotic prophylaxis is
unnecessary in neonates with cholestasis. Prophylactic antibiotics should be used to prevent endocarditis in susceptible patients
in the same manner as for upper gastrointestinal endoscopy. Special situations that require a valvular prosthesis, vascular
graft material, indwelling catheters, or transplanted organ in an immunosuppressed patient need individual consideration.
Additional medications, which may be useful during ERCP, include glucagon and buscopan (hyoscine-N-butyl bromide) to reduce
duodenal motility, and secretin to facilitate identification and cannulation of the minor papilla.
In neonates and infants younger than 12 months, ERCP is performed with a special Olympus pediatric duodenoscope PJF  (Olympus America Inc., Melville, NY) which has an insertion tube diameter of 7.5 mm, a channel of 2.0 mm, and an elevator. A standard adult duodenoscope (insertion tube diameter approximately 11 mm) can be used for older children and adolescents. Therapeutic maneuvers, such as placement of endoprostheses and passage
of some dilators and retrieval baskets, require instruments with a larger (3.2 mm) channel.
ERCP is performed in a radiology suite. Pediatric endoscopy assistants and specially trained nurses can help reduce pre-procedure
anxiety, monitor the clinical status of the patient, and assist in holding and reassuring, administering medication, handling
catheters, and injecting contrast material. The heart rate and oxygen saturation must be continuously monitored. Resuscitation
medications and appropriate equipment should be available. ERCP is performed on an ambulatory basis. A recovery area equipped
with monitors and specialized pediatric nurses familiar with the needs of children is necessary.
The principles of cannulation are those used in adult patients, with the additional limitations of space within the duodenum
that depend on age. In young infants, such as those undergoing investigation for neonatal cholestasis, it is important to
minimize the procedure time to avoid abdominal overdistension and respiratory compromise.
In general, children with suspected biliary and pancreatic disease should undergo MRCP nowadays before considering ERCP (which
is more often used for therapy).
The only indication of ERCP in neonates and young infants is cholestasis. Biliary indications for ERCP in children older than
1 year and in adolescents are:
- obstructive jaundice
- known or suspected choledocholithiasis
- abnormal liver enzymes in children with inflammatory bowel diseases
- evaluation of biliary ductal leaks after cholecystectomy or liver transplantation
- evaluation of abnormal scans (ultrasound, computerized tomography (CT), or MRCP)
- therapeutic ERCP.
Pancreatic indications for ERCP in children are:
- non-resolving acute pancreatitis
- idiopathic recurrent pancreatitis, chronic pancreatitis
- evaluation of persistent elevation of pancreatic enzymes
- evaluation of abnormal scans (ultrasound, CT, or MRCP)
- evaluation of pancreatic pseudocysts and pancreatic ascites
- evaluation of pancreatic ductal leaks from blunt abdominal trauma
- therapeutic ERCP.
Success rates for ERCP in children
Successful cannulation of the common bile duct in neonates and young infants is lower than in adults. It varies from 27% to
95% according to the endoscopist's experience  (Fig. 1). In our unpublished experience with 184 neonates and young infants with neonatal cholestasis, the procedure was successful
technically in 93% of the cases. Failure was due to duodenal malrotation in two cases and inability to cannulate in six.
In older children, the success rate for cannulation of the desired duct is comparable to that achieved in adults  (Fig. 2). Our ERCP success in 220 children older than 1 year was 98%.
The incidence of complications in pediatric patients is not well established. In neonates and young infants with neonatal
cholestasis there were no major complications in the series reported in the literature . In our unpublished experience with 184 neonates and young infants, minor complications without clinical significance occurred
in 24 patients (13%). Two neonates had transient narcotic-induced respiratory depression and four young infants had non-narcotic
respiratory depression, which resolved with oxygen administration. In 17 patients, minor acute duodenal erosions were observed
without clinical consequences. One neonate had abdominal distension for 10 h after completion of ERCP, which resolved without
treatment. There were no major complications.
Complications in children older than 1 year vary according to the system studied, biliary or pancreatic. The overall incidence
is approximately 4.7% . In our unpublished experience with 220 ERCPs in children older than 1 year, ERCP was performed for diagnostic purposes in
108 cases with 2 (1.8%) complications. In 112 therapeutic ERCPs, complications occurred in 12 (10.7%).
Biliary findings (Fig. 3)
Biliary atresia vs. neonatal hepatitis
The differential diagnosis of neonatal cholestasis is critical in the first 2 months of life. In approximately 30% of patients
a specific metabolic or infectious disease can be recognized. In the remaining 70% of neonates the key differentiation is
between biliary atresia and neonatal hepatitis. Discriminating analysis using duodenal drainage, ultrasound, scintigraphy,
and liver biopsy permitted accurate diagnosis of either biliary atresia or neonatal hepatitis in 8090% of patients . Thus, 1020% of neonates required laparotomy to establish the diagnosis. In these patients, visualization of a patent biliary tree
by ERCP may help.
Clearly, the success of ERCP in this context depends upon the experience of the endoscopist, who must have confidence that
non-visualization of the common bile duct was not related to technical problems and to positioning the catheter. ERCP is the
most direct method of establishing a diagnosis in the hands of skilled endoscopists, and may be appropriate as the first-line
test when expertise and equipment are available.
Three types of ERCP findings have been described in patients with biliary atresia  (Fig. 4). Type 1, no visualization of the biliary tree (Fig. 5); Type 2, visualization of the distal common duct and gallbladder (Fig. 6); Type 3, is divided in two subtypes: Type 3a, visualization of the gallbladder and the complete common duct with biliary
lakes at the porta hepatis (Fig. 7), and Type 3b, in which both hepatic ducts are seen with biliary lakes.
Several authors [2,46,27] have shown that in half of the patients in whom extensive investigations failed to distinguish intra- from extrahepatic cholestasis,
the biliary tree was opacified, thus avoiding surgery. When the biliary tree was partially visualized (Type 2 and Type 3)
the diagnosis of biliary atresia was made and confirmed by surgery. When the biliary tree was not opacified and only the pancreatic
duct was visualized (Type 1), the diagnosis of biliary atresia was suspected and exploratory laparotomy was indicated. Of
the 310 infants with neonatal cholestasis reported in the literature (Fig. 8), the diagnosis by ERCP was incorrect in only 5 (1.6%) patients.
Miscellaneous genetic cholestatic diseases
In Alagille syndrome, the extrahepatic ducts are normal. ERCP shows marked and diffuse narrowing of the intrahepatic duct
and reduced arborization [27,28]. Congenital hepatic fibrosis is characterized by disordered terminal interlobular bile ducts, which form multiple macroscopic
and microscopic cysts (Fig. 9) that can be demonstrated by ERCP . In Caroli's disease there are multiple segmental cylindrical or saccular dilatations of small biliary radicals with normal
common bile duct that can be demonstrated by ERCP . Diagnosis of these conditions is necessary in order to avoid needless surgery.
Bile plug syndrome
Bile plug syndrome represents a correctable cause of obstruction of the extrahepatic bile ducts by bile sludge in patients
with normal biliary tract. The diagnosis is suspected by ultrasonography and confirmed by ERCP, which offers therapeutic possibility.
Improvements of patients after ERCP suggest that simple irrigation with contrast material may be helpful .
Choledochal cyst is a congenital malformation of the biliary tract characterized by saccular dilatation of the biliary tree.
Choledochal cyst is primarily a disease of children and young adults, and 60% of reported cases are diagnosed before age 10
. The diagnosis of this congenital malformation of the biliary tract is made by abdominal ultrasound, CT, or MRCP. ERCP confirms
the diagnosis and helps surgical planning.
Pathogenesis of choledochal cyst
Many theories have been proposed to explain the development of choledochal cysts. The more generally accepted theory proposes
that cysts are acquired. The majority of patients with choledochal cysts have an anomalous pancreatico-biliary union  located outside the duodenal wall (Fig. 10) and are not under the influence of the sphincter of Oddi mechanism. According to this theory, there is reflux of pancreatic
juice upward into the biliary system that can produce damage to the common duct lining resulting in saccular dilatation of
the duct .
The maximum normal length of the common channel in neonates and infants younger than 1 year is 3 mm. It increases with age to a maximum of 5 mm in children and adolescents between 13 and 15 years of age .
Classification of anomalous ductal union
There are three types of anomalous ductal union . If it appears that the pancreatic duct is joining the common bile duct it is denoted as PB type. If the common bile duct appears to join the main pancreatic duct it is denoted as BP type, and if there is only a long common channel it is denoted as Long Y type (Fig. 11).
Classification of choledochal cysts
The anatomical classification by Todani et al.  of bile duct cysts is most often used (Fig. 12).
The Type I cyst is the most common and accounts for 8090% of all choledochal cysts . Type I is subdivided into: Type A, a typical cyst dilatation of the choledochus; Type B, segmental choledochal dilatation;
and Type C, diffuse or fusiform dilatation (Figs 13 and 14).
Type II is a diverticulum anywhere in the extrahepatic duct.
Type III, a choledochocele, involves only the intraduodenal duct.
Type IV represents multiple intrahepatic and extrahepatic cysts (Fig. 15).
Type V (Caroli's disease) includes single or multiple intrahepatic cysts.
Although classified as one of the forms of choledochal cysts, choledochocele is probably not related. It is a rare cause of
obstructive jaundice. The diagnosis is established with certainty by ERCP, and it may be effectively treated with endoscopic
The presence of a distal bile duct stricture at its point of connection with the pancreatic duct is frequently observed (Fig. 15). Primary cystolithiasis occurs in 8% of patients and usually is multiple (Fig. 14), involving intrahepatic and extrahepatic ducts .
Treatment of choledochal cysts
The anomalous anatomical configuration of the pancreatico-biliary ductal system observed in most patients with choledochal
cysts has certain technical implications in regard to management. In most patients, endoscopic sphincterotomy is probably
not indicated, and endoscopic access to the biliary system for removal of stones or sludge is therefore not possible. In selected
cases, with fusiform bile duct dilatation and widely dilated common channel, endoscopic sphincterotomy has been attempted,
with encouraging results .
Fusiform choledochal dilatation and carcinoma
Fusiform choledochal dilatation, as opposed to cystic dilatation, has been observed to be more commonly associated with low-grade,
short strictures located at or distal to the pancreatico-biliary junction . Moreover, carcinoma seldom, if ever, develops in fusiform dilatation .
Primary sclerosing cholangitis
In children, primary sclerosing cholangitis (PSC) is associated with histiocytosis X , immune deficiency states , and, less frequently, in patients with reticular cell sarcoma  and sickle cell anemia . The association with inflammatory bowel disease is relatively uncommon (14%), suggesting that genetic and immunological
factors are the most important factors [47,48].
Most benign biliary strictures in children are due to sclerosing cholangitis. ERCP provides an accurate and sensitive method
of diagnosing sclerosing cholangitis. Recently, MRCP has been shown to be a useful non-invasive diagnostic technique . The cholangiogram will show pruning of the peripheral biliary tree and areas of stenosis and ectasia [27,48]. Patients with major ductal strictures are candidates for endoscopic treatment with sphincterotomy and balloon dilatation
to relieve the obstruction in order to delay the progression to cirrhosis . Hydrostatic balloon dilatation has been used to dilate biliary strictures . We developed a tapered hydrophilic balloon to dilate hepatic duct strictures and to avoid small intrahepatic duct rupture
Ascaris infestation can produce acute biliary obstruction with cholangitis. The worm can be seen with ERCP and can be removed with
a tripod basket .
Choledocholithiasis occurs rarely in both infants and children . Conditions associated with the presence of stones include biliary tract malformations such as choledochal cyst, chronic
liver disease, hemolysis, and infection. The diagnostic approach is more difficult, and identification of the cause of obstruction
by ultrasonography is often impossible. MRCP is the best non-invasive technique in demonstrating common bile duct stones and
is clearly superior to ultrasonography .
ERCP for stones
The role and value of ERCP and endoscopic sphincterotomy in children with choledocholithiasis are not well established. Sphincterotomy
with common bile duct stone removal has been successfully performed in young infants , and in children and adolescents [11,5660]. Endoscopic papillary balloon dilatation with stone extraction is an alternative technique for stone removal . However, pancreatitis can occur in 7% of cases. In children, published experience with this technique is limited .
Most infants with asymptomatic gallstones and no factors that would make them susceptible to stone formation can be managed
conservatively . However, larger stones are less likely to resolve, whereas smaller stones, sludge, and mucus should be able to pass in response
to oral feeding without symptoms or complications. In children, sphincterotomy should be reserved for symptomatic patients
or those with underlying lithogenic disorders.
A combined endoscopic sphincterotomy with common stone extraction followed by laparoscopic cholecystectomy has been successfully
reported in children . Although the combined procedure seems to be safe, additional experience is awaited so that the true advantages, limitations,
and complications of this approach can be placed into clinical perspective.
Biliary strictures and leaks
Primary stricture of the common hepatic duct has been reported . Hydrostatic balloon dilatation may be use in the treatment of dominant common duct strictures .
Malignant strictures of the common bile duct are uncommon in children and have been successfully treated by placements of
In patients whose liver is transplanted, the integrity of the anastomosis can be studied. ERCP is an alternative to percutaneous
transhepatic cholangiography, and is the procedure of choice in patients with coagulopathy when the biliary tree must be imaged.
When a stricture is found, the area may be dilated and a stent may be placed for a limited period of time.
Bile leaks may be found and can be treated by endoscopic sphincterotomy or with stent placement .
Pancreatic findings (Fig. 17)
ERCP has been found useful in the identification of treatable causes in approximately 75% of children with recurrent pancreatitis
[1014,18,21,24,6870]. Whatever the etiology of pancreatitis, the possibility of an anatomical abnormality amenable to endoscopic therapy or surgery
should always be considered.
The timing of performing an ERCP in children is controversial. In children with idiopathic pancreatitis in whom recovery has
occurred with standard medical treatment, there is no consensus as to when an ERCP to look for an obstructive cause is indicated.
The potential benefit of proceeding with ERCP after the first episode as opposed to waiting for a second attack of pancreatitis
is, of course, of preventing that second episode with its associated morbidity and mortality. No randomized controlled clinical
trials have been performed that directly address this issue. Although not reported in the literature, it is the experience
of the author that children with normal MRCP after the first episode of pancreatitis should not be studied.
Choledochal cyst and anomalous pancreatico-biliary union
Choledochal cysts have been associated with recurrent pancreatitis in 618% of the cases [913,18,21,69,70]. An anomalous pancreatico-biliary union has been observed in most children with choledochal cysts and recurrent pancreatitis
(Fig. 18)[37,71,72]. In this subgroup of patients, sphincter of Oddi dysfunction has been demonstrated, suggesting that this motor abnormality
might be related to the development of recurrent pancreatitis . Moreover, because the sphincter of Oddi muscular segment is located within the duodenal wall, endoscopic sphincterotomy
prior to surgery has been performed with excellent results, supporting this theory . Occasionally, pancreatic stones or protein plugs may be endoscopically removed (Fig. 19). Choledochoceles have been reported in patients with recurrent pancreatitis [27,73,74]. Treatment by endoscopic sphincterotomy provides excellent results [70,75].
Pancreas divisum is a congenital anomaly caused by failure of fusion of the dorsal and ventral endodermal buds. Each duct
drains via its own separate orifice, the major papilla of Vater for the ventral duct of Wirsung, and the minor accessory papilla
for the dorsal duct of Santorini.
Prevalence of pancreas divisum
Pancreas divisum is the most common congenital anomaly of the pancreas. In adults, it has been found in 514% of autopsy series and 0.38% of ERCP studies [76,77].
The prevalence of pancreas divisum in children is not known. In our experience with 272 consecutive cases of successful ERCP
performed in children, pancreas divisum was found in 9 (3.3%) children . Two patient groups were identified on the basis of the age at which ERCP was performed. Group 1 included 147 neonates or
young infants in which ERCP was performed to evaluate neonatal cholestasis. Two (1.4%) neonates had pancreas divisum, one
with neonatal hepatitis and the other with biliary atresia. Group 2 included 125 children older than 1 year in which ERCP
was performed to evaluate pancreatic and biliary disorders. Seven (5.6%) children had pancreas divisum.
Significance of pancreas divisum
The clinical significance of pancreas divisum is controversial. An association between pancreas divisum and pancreatitis has
been suggested [76,7983]. However, others  have considered it to be a coincidental finding. It appears that the combination of pancreas divisum with accessory papilla
stenosis would lead to a real functional obstruction. In 296 children with recurrent pancreatitis, pancreas divisum has been
found in 10.8% of patients (Fig. 20).
ERCP diagnosis of pancreas divisum
ERCP is mandatory in the diagnosis of pancreas divisum. Cannulation of the major papilla shows a short duct of Wirsung (ventral
pancreas) that quickly tapers and undergoes arborization (Fig. 21). To confirm the diagnosis it is most important to cannulate the minor papilla to demonstrate the dorsal pancreas. Interventional
treatment in patients with pancreas divisum is applied to those whose symptoms are disabling.
Treatment of pancreas divisum
Surgical minor papilla sphincteroplasty used to be the treatment of choice, with a 70% improvement . Endoscopic treatment has been utilized to decompress the dorsal duct by a variety of methods, including endoscopic minor
papilla sphincterotomy with or without insertion of an endoprosthesis.
Endoscopic sphincterotomy of the minor papilla is indicated in patients with disabling symptoms. It has been attempted in
conjunction with temporary stent placement in the dorsal pancreatic duct (Fig. 22), and has led to improvement in approximately 75% of children [16,18,70]. Overall, these results indicate that in certain children with recurrent pain or pancreatitis and pancreas divisum, endoscopic
therapy can offer relief or improvement in symptoms.
Other pancreatic congenital anomalies
Annular pancreas has been associated with recurrent pancreatitis in children [70,89,90]. However, the relationship with pancreatitis is unclear. In 14 cases of annular pancreas reported in the English literature
there were 5 with coexistent pancreas divisum, suggesting that pancreas divisum occurs more often in the presence of annular
pancreas than in the general population . This association may explain pancreatitis in some patients.
Other pancreatic congenital anomalies found to cause pancreatitis include short pancreas [70,91] and cystic dilatation or pancreatocele of the distal pancreatic duct .
Duodenal duplication cyst
Duodenal duplication cyst is a congenital anomaly which has been associated with recurrent pancreatitis due to intermittent
obstruction of the pancreatic duct [92,93]. ERCP has been shown to be useful in the diagnosis as well as for definitive treatment . If the cyst is bulging into the intestinal lumen, a wide cystoduodenostomy can be endoscopically performed, with excellent
Sphincter of Oddi dysfunction
Sphincter of Oddi manometry is the diagnostic procedure of choice for this functional motor disorder. It was found in 17 out
of 139 (12.2%) children with recurrent pancreatitis [9,16,18,70]. These patients are generally treated by standard biliary sphincterotomy and, in general, they do not respond well , presumably because the pancreatic sphincter is not transected. Recurrent attacks of pancreatitis may be attributed to an
affected pancreatic sphincter . Dual endoscopic sphincterotomy of the pancreatic and common duct sphincters may be necessary to improve outcome . However, safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further
Recent evidence has suggested that it is safe to perform ERCP during non-resolving traumatic pancreatitis and it may be helpful
in identifying the need for endoscopic therapy or surgery . Early ERCP may identify the presence and location of duct leakage. Patients with normal ductograms are treated conservatively.
Successful treatment by placement of an intrapancreatic ductal stent may be possible at the same time . Surgical resection or reconstruction can then be reserved for cases in which stenting is impossible or fails.
Acquired immunodeficiency syndrome
Little has been written regarding pancreatic involvement in children with AIDS. Opportunistic infections may involve the pancreas,
just as they do the other digestive organs in children with AIDS . Most common are cytomegalovirus and Cryptosporidium, followed by Pneumocystis carinii, Toxoplasma gondii, and Mycobacterium avium. Drug-induced pancreatitis is a common complication of pentamidine  and dideoxyinosine . ERCP has been shown to be useful in the evaluation and treatment of children with AIDS [101,102]. Pancreatic duct dilatation in two children with pancreatic duct stricture produced significant clinical improvement of pain.
ERCP has been found useful in the identification of chronic pancreatitis in 1469% of children with recurrent pancreatitis [922,69,70]. Two major morphological patterns can be demonstrated: (a) chronic calcifying pancreatitis, most often due to hereditary
pancreatitis, fibrosing pancreatitis, or juvenile tropical pancreatitis; (b) chronic obstructive pancreatitis, which is associated
with congenital or acquired lesions of the pancreatic duct, or biliary tree similar to those etiological factors found in
In children with chronic pancreatitis, debilitating pain and recurrent attacks may be caused by strictures of the main duct,
pancreatic stones, or pseudocysts that impair the normal outflow of pancreatic juice. ERCP demonstrates evidence of these
abnormalities that can be treated endoscopically [10,1416,18,24,70,103].
Endoscopic treatment of chronic pancreatitis in children
The aim of endoscopic therapy is based on the concept of pancreatic duct decompression. Pancreatic sphincterotomy has been
performed to improve pancreatic drainage and to allow intraductal therapeutic maneuvers, severe stenosis has been dilated
and bypassed with stents, and obstructing ductal stones have been removed after destruction by electrohydraulic lithotripter
or extracorporeal shock-wave lithotripter [Fig. 23]. These endoscopic techniques constitute an excellent alternative to relieve recurrent abdominal pain and to avoid progressive
parenchymal damage to the gland.
Pancreatic endotherapy has been reported in children in abstract form in five different centres [1820,22,88], demonstrating that endoscopic pancreatic therapy in childhood is well tolerated, safe, and likely to be technically successful
in experienced hands. Overall, there is an 80% short-term symptomatic improvement after pancreatic endoscopic therapy in children
with chronic pancreatitis [10,18,70,103]. A longer follow-up period will be necessary to determine whether endoscopic success produces long-standing clinical improvement.
Pancreatic pseudocysts are common consequences of acute and chronic pancreatitis. Most of the pseudocysts resolve spontaneously.
Symptomatic, large (> 4 cm), or persistent pseudocysts beyond 6 weeks are unlikely to resolve and are at risk of complication . In these cases treatment is indicated. Recently, there has been increased interest in non-operative management of pancreatic
pseudocysts. Endoscopic methods have been developed as an alternative to surgical treatment and percutaneous drainage of pseudocysts.
These endoscopic methods include endoscopic cystogastrostomy, cystoduodenostomy, and transpapillary drainage (Fig. 24). In adults, successful pseudocyst resolution has been reported in approximately 80% of cases . As with other therapeutic interventions, pediatric experience is limited to a few case reports [9,18,70,103].
Outstanding issues and future trends
ERCP is an established procedure in children. Even though there is an increased number of pediatric gastroenterologists doing
ERCP, there is not enough volume for them to gain proficiency. This has become more apparent since, nowadays, ERCP is less
diagnostic and more therapeutic. It is my belief that, in future, ERCP in children will be performed by highly trained endoscopists
working in tertiary care facilities, which maintain a high volume of such activity. Further studies should be directed to
assess the usefulness of MRCP in the diagnosis of biliopancreatic diseases in children. In general, children with suspected
biliary and pancreatic disease should undergo MRCP before ERCP is considered, with the latter increasingly being reserved
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