Even at a high-volume tertiary care pediatric endoscopy center, use of endoscopic ultrasound (EUS) is relatively limited in children compared with adults, reported experts from Stanford University School of Medicine at the 2021 Digestive Disease Week.
Using their prospectively maintained endoscopy database, the investigators identified patients 18 years of age and younger who underwent EUS for all indications between July 2009 and July 2019. Over that 10-year period, 219 EUS procedures were performed for 201 pediatric patients (aged 3-18 years). Procedures included 205 (93.6%) upper EUS and 14 (6.4%) lower EUS procedures; 81.7% were diagnostic and 21.4% were therapeutic. “The vast majority of procedures (217/219; 99%) were technically successful,” reported the investigators, led by Monique Barakat, MD, an assistant professor of pediatrics (gastroenterology) and medicine (gastroenterology and hepatology) at Stanford’s Lucile Packard Children’s Hospital, in California. The team reported neither associated adverse events nor intraoperative/delayed complications.
“EUS is a modality that we use every single day in the adult population, and yet in surveys we have done of pediatric practice, we have found that less than half of all centers offer pediatric EUS, often only from providers who specialize in adults,” Dr. Barakat told Gastroenterology & Endoscopy News (J Pediatr Gastroenterol Nutr 2019;69[1]:24-31). As practitioners at “one of the only centers that performs pediatric EUS in significant volumes, we thought that it would be important to characterize how we use it at our center,” Dr. Barakat said. “With this hypothesis-generating, information-building single-center study, we hope to spur other studies cataloging the role of EUS at other centers.”
Although even at Stanford, the number of pediatric EUS procedures performed averaged out to a little more than 20 per year, Dr. Barakat and her colleagues found a statistically significant increase in the use of EUS and proportion of therapeutic EUS procedures over time (P<0.001).
“When you are performing about 20 procedures a year, that’s just not enough to really get people trained and proficient at EUS, but it is striking that even in this small group of patients that Stanford is using it in, they’re clearly finding it useful,” said Jenifer Lightdale, MD, the chief of the Division of Pediatric Gastroenterology at UMass Memorial Medical Center, in Worcester, Mass.
A Missed Opportunity
The relative rarity of pediatric EUS represents a significant missed diagnostic opportunity, Dr. Barakat said, noting that recent work found that some pediatric endoscopic retrograde cholangiopancreatography (ERCP) procedures are performed for diagnostic indications. “ERCP should be a therapeutic procedure, but in a comprehensive study of nationwide trends published in May, we found that up to 20% of ERCPs in children are performed for diagnostic reasons,” Dr. Barakat said (J Pediatr 2021;232:159-165.e1). “For reference, that percentage in the adult population is closer to 4% to 5%,” she said. “It’s very rare to use diagnostic ERCP in an adult. In situations where you’re not sure if an ERCP is necessary—for example, if the bilirubin is a little high and you suspect there might be a stone in the bile duct—you typically do an EUS to check. And then, if the stone is present, then you do the ERCP. But that’s not typically how it’s happening in pediatrics.”
Overuse of diagnostic ERCP carries risk in children and adults. “EUS has a safety profile that is almost unparalleled with endoscopic procedures, while ERCP or other surgical approaches have much higher adverse event rates,” Dr. Barakat said. “Conducting ERCP for just a diagnostic indication exposes the patient to the risk of post-ERCP pancreatitis, as well as bleeding, infection and perforation.”
Because EUS is less invasive and less risky than ERCP, Dr. Barakat said it may be possible to adapt training pathways for pediatric EUS. “Getting a therapeutic EUS for a pediatric patient with a pancreatic fluid collection, for example, might still require a transfer to a higher-volume center,” she said. “But I would think that many parents, if they were offered the choice between a transfer for a minimally invasive approach versus an open surgery or a procedure that requires a drain, would choose the former. But that’s not necessarily being offered to them right now.”
In a related abstract also presented at DDW, Dr. Barakat’s group reported on the apparent underuse of ERCP in a therapeutic context in the pediatric population, specifically for the management of large bile duct obstruction. Noting that their data on adults show that more than 80% of patients with histologic evidence of large duct obstruction who undergo ERCP “have biliary findings amenable to endoscopic therapy,” they added that the utility of ERCP in this setting has not been studied in pediatrics.
The investigators reviewed pathology and clinical records from 85 pediatric patients in their practice with large bile duct obstruction on liver biopsy from 2010 to 2019, and found that 15 (17.6%) underwent ERCP; in contrast, 48.1% of adult patients in their practice with large bile duct obstruction on liver biopsy undergo ERCP. “This may reflect underutilization of ERCP in this clinical context in pediatrics, as 80% of these ERCP patients underwent endoscopic intervention that favorably impacted their clinical trajectory,” the investigators reported.
“We find a lot of intervenable findings in adults, and this study suggests that we may be missing those in children,” Dr. Barakat said. “The consequences of missing these could mean that a transplanted liver might not last as long, or an obstruction could go unchecked, leading to cirrhosis and the need for a liver transplant.”
Dr. Lightdale agreed. “I think they are completely correct in what they’re reporting at their center,” she said. “I suspect we are not using these advanced procedures when we need to in children, and if ERCP in this indication is underutilized even at a great center like Stanford, it’s probably being underutilized everywhere.”
Dr. Barakat recommended that additional multicenter studies involving more patients be conducted, focused on understanding the utility of ERCP and range of outcomes after the diagnosis of large bile duct obstruction in pediatrics.
—Gina Shaw
Drs. Barakat and Lightdale reported no relevant financial disclosures. Dr. Lightdale is a member of the editorial board of Gastroenterology & Endoscopy News.
This article is from the December 2021 print issue.