In this episode, Dr. Temara Hajjat and Dr. Jenn Lee discuss with Dr. Roberto Gugig from Stanford's Lucile Packard Children's Hospital the indications, techniques, and potential complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in pediatric patients.
Dr. Gugig is a pediatric gastroenterologist and Professor of Pediatrics who specializes in advanced endoscopy including ERCP and EUS.
Objectives:
1. Diving into the science of pediatric ERCP and EUS imaging.
2. Unpacking the intricacies of diagnosing pancreaticobiliary disorders in children using EUS or ERCP.
3. Shedding light on higher complication rates in patients under two years old and how to mitigate them.
This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!
This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!
As always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.
Check out our merch website!
Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes.
Click here to support the show.
In this episode, Dr. Temara Hajjat and Dr. Jenn Lee discuss with Dr. Roberto Gugig from Stanford's Lucile Packard Children's Hospital the indications, techniques, and potential complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in pediatric patients.
Dr. Gugig is a pediatric gastroenterologist and Professor of Pediatrics who specializes in advanced endoscopy including ERCP and EUS.
Objectives:
1. Diving into the science of pediatric ERCP and EUS imaging.
2. Unpacking the intricacies of diagnosing pancreaticobiliary disorders in children using EUS or ERCP.
3. Shedding light on higher complication rates in patients under two years old and how to mitigate them.
This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!
This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!
As always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.
Check out our merch website!
Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes.
Click here to support the show.
Welcome to another episode of Bow Sounds, the official podcast of the North American Society of Pediatric Gastroenterology, hepatology and Nutrition, or NASPGN. My name is Tamara Hedgett, I'm a pediatric gastroenterologist at Cincinnati Children's and I'm joined today by my co-host, dr Jen Lee.
Speaker 2:Hello Tamara, so good to see you.
Speaker 1:I feel like you know the price is right. Jen, come down.
Speaker 2:Well, my head immediately went to one of those NBA or like a basketball game where I'm like coming in, everyone's screaming and yelling. Maybe it'll be like that at NASPGN, just kidding. So how are you? What are you doing these days? I have been seeing you. I need an update on your cat because I saw you post a couple of reels about her.
Speaker 1:And she's adorable.
Speaker 2:Does she not run away like she's outside?
Speaker 1:No, she doesn't run away. So we go outside every evening between depending on like how hot it is outside, so it's usually between 7.30 and 8.30. And she knows that she's going to go out, so she goes. She walks like right in front of me. She goes and sniffs some flowers, eats some grass, walks around and then when she's done she either goes to the front door or I'm like and then I clap, and then she just runs up to the front door and goes in. So she is a very well-behaved cat and I'm lucky I opened her own TikTok. She has a TikTok account.
Speaker 2:I love that. Do you have catnip in your yard? Because I heard that catnips really can make cats get a little bit more active she actually.
Speaker 1:The only time I give her catnip is when she goes to the vet just to reduce her anxiety, and she sleeps for two days after she gets that catnip.
Speaker 2:It's just so crazy to me that you can just grow it in your yard. I actually Googled it just now and apparently it's like an insect repellent.
Speaker 1:It's mint. It's kind of like spearmint or peppermint. It's like a mint plant.
Speaker 2:Yeah, but it says, if you give too much of it, that's when they get really sleepy, so don't give too much.
Speaker 1:I give her just a little bit, just a teeny tiny, and I rub it, but she just has that effect. My brother's cats, once they take catnip, they like roll in it and start playing in it and they go crazy. They have the opposite effect.
Speaker 2:I love that, hey, so we have a really cool episode today. We are going to be talking about a follow up, advanced endoscopy episode.
Speaker 1:Right, right. So we have the perfect person for it. We're going to talk about ERCP and EOS. We have Dr Robert Gugick from Stanford. I met him during the junior faculty meeting last I think it was November or October. It was actually kind of the first. It was the second one, but it was the first one since the first one started, which was like three or four years ago, and we were both sitting at the same table and I was like, oh my gosh, he is so funny, he's so great. He gave a lecture about career development and he gave a lecture about promotion, but he is an expert advanced endoscopist, as you will hear. He does a lot of ERCPs and EOS, he trains with adults and he is the perfect person for our topic today.
Speaker 2:Yeah, so glad that we're having him. For anyone who hasn't listened, we did do an intro to advanced endoscopy with Dr Brad Barth in season two, tamara, do you remember? We did that one together? I do. He talks a lot about how to get the training and what it is, and today we get into a little bit more of the specifics. So we really hope everyone loves the episode.
Speaker 1:And there is going to be a pediatric GI chat on Twitter with Dr David Vitale. So a lot of ERCP experts and EOS experts. So, yeah, make sure to join in. It's going to be on Thursday at 7pm Eastern time.
Speaker 2:Awesome, ready One, two, three. On to the show.
Speaker 1:Welcome Dr Gugik to this podcast. We're excited to have you today. Thanks for making the time to join Yay.
Speaker 3:I'm excited to be here.
Speaker 1:I have to be honest, since we met, like during the first I think it's a second junior faculty meeting, which was great. You should definitely sign up for it. We met there. I think we were sitting on the same table and we just like chatted and I was like, oh my gosh, dr Gugik is like so hilarious, so funny, we have to have him on the podcast. So knowledgeable, I don't know. We talked about a lot of products and I was like, oh my gosh, we have to have him on the podcast. So welcome.
Speaker 3:Thank you very much.
Speaker 1:So I'm going to start with our first question. Some people find it challenging, others perfect it, although not a lot. But how would you describe yourself in one sentence to our listeners?
Speaker 3:I'm a gastroenterologist that loves to do endoscopy, and so I pursued extra training for that. That's how I would describe myself.
Speaker 1:That's great. Your training is amazing and that's why we have you on today, because we want some of your knowledge. I'm happy.
Speaker 3:Hopefully you can gain some knowledge from this.
Speaker 2:So this is a new question for this season. But if we were going to visit you in San Francisco? So for those who aren't on our Zoom call, he has the Golden Gate Bridge behind him. What do you recommend that a typical tourist or someone just coming to San Francisco may miss?
Speaker 3:Yeah, I think there's a little bit of everything. I like cycling. There's great places to cycle in San Francisco. I also like going to good restaurants, and there's plenty of restaurants from all type of backgrounds and types of food and from cheap to Michelin star restaurants. And then people like wine can go up to Napa and spend some time there, and then obviously there's museums and beaches. So there's a little bit for everybody. I think even the kids too very old people, can have fun here.
Speaker 1:That's great. I remember when I went to San Francisco I went to the Japanese Garden.
Speaker 3:Yes, and Gold City Park.
Speaker 1:Yes, it is so beautiful, that park is so nice, it has a lot of great stuff and I ate a lot of good food there.
Speaker 3:You have the great Science Museum in the park. You can take the kids it's great as well and the park itself is beautiful.
Speaker 1:Yes, I'm definitely planning on going there again, so we'll see, maybe this summer or next summer. So moving on, just to kind of learn a little bit more about how much you like endoscopies, how did you first develop your interest in pursuing a career in advanced endoscopy?
Speaker 3:Yes, so I trained at UCSF and we had a lot of relationship with the adult folks at UCSF. Now it's a separate children's hospital, but when I trained it was all in the same adult hospital. So we had a pediatric floor. So we interacted a lot with the adults and there I got to know a lot of the adult procedures that they'd normally do that are less frequent in pediatrics. So I got acquainted with ERCPs and endoscopic ultrasounds and I played around with the first endoscopes prototypes that they had at the time.
Speaker 3:I just became fascinated with all that technology and obviously something that we did not have on the pediatric side. We used at that time the adults. Anytime a pediatric patient required it, we had to call the Billery Fellow and have them come over. And so I said, how do I get trained in this? And of course then began the long road because there's no training set up, such as an adult, so an adult. It's like doing an extra year of like hepatology or IBD et cetera. You know it's an extra year of advanced endoscopy and they have it very well organized.
Speaker 3:There's a match program. You can look at all the programs. You can see what procedures they do, what the volume is. It's very well organized. There's nothing like that, of course, in pediatrics and so and it is not easy for us to apply and get accepted in an adult program because most programs expect the fellows to be on call for adults and you know, the last time I saw an adult patient was like in medical school, so we're not very useful there. So that's very tough right. And so I had to piecemeal my training and so it took me a lot longer than one year to do this, because I actually trained in endoscopic ultrasound first and in terroscopy and pollen before I did ERCP. So it took me many years to achieve that training. So it's a long road, but I think it's a little bit better now than it was when I went through that path. But that's how I got into what is considered advanced endoscopy.
Speaker 2:So just to take on to that, many of our fellows who may be interested, what quick advice would you have for them if they're interested in doing this now?
Speaker 3:Yeah, I think to speak to one of the people that have been trained and have gone through the path of training, because it has not been uniform so people have gone through different paths to achieve the same goals. So definitely in pediatrics I don't think there's one scissor that cuts for everybody. So I think to speak to the different people that have gone through the process and see what opportunities they may have depending on what part of the country they live in.
Speaker 2:That's really great to know and I love that we actually have pediatric advanced endoscopy, because that's what it was at my fellowship as well, and the patients always had to be a certain age or certain size and we really sometimes felt like our hands were tied, especially for these younger kids. So kind of moving a little bit more into the clinical practice part of this. So you mentioned endoscopic ultrasound and ERCP, so can you walk us through primary indications for using these techniques and how do they differ from adults?
Speaker 3:Yes, I think that we all learn these techniques from the adult side, and that's just a matter of volume.
Speaker 3:I mean to give you some examples. Where I trained in, ercp was a very big adult center and they did about 18 to 1900 ERCPs per year, and the largest programs that we have in pediatrics and the very big academic centers I mean the largest programs probably do maybe 150 to 200 ERCPs per year. So you can see the difference in volume and therefore most of us learned a technique on adults and therefore we learn the adult indications and then we are now tasked with using this technology into in the pediatric world and certainly some indications may be similar, for example, if you have a stone in the bile duct and you want to remove it. So that's a very common adult indications, but other indications may be unique to pediatrics. I just did a bronchogenic cyst ablation in a two year old and that's something I never did as adults right On adults. So we see a lot of congenital anomalies that they don't see on the adult world. Then we may be able to tackle using the same technology that we learn from the adults but applied on pediatrics.
Speaker 1:Wow, yeah, that's very interesting. Kind of going into our next question, you kind of touched upon the differences between adults and pediatrics for indication of an E, us and ERCP, but talking about technical aspects, and you said that some things that you do in pediatrics you've never done in adults. What are the major differences between adults and pediatrics, technique wise, when you're doing an E, us and ERCP, and what are the complications that you would anticipate in kids that you don't look out much for in adults?
Speaker 3:You know, for pediatric patients, always the main issue is the size of our patients, correct? So the equipment we use for ERCP in US is designed for adult patients, right? So we do not have specifically designed equipment for pediatrics. I guess one exception I'll take this opportunity of the podcast to mention it is we have one very small old scope from Olympus, which was developed actually as a prototype scope, which is the only due denoscope that we have that we can use in children that are less than 10 kilos. It's a scope from the 90s Wow, very few in the country. It has a diameter of seven and a half millimeters and a two millimeter working channel and we do not have a replacement. We don't have an alternative and, by the way, this is not only in the United States but the world and some of the people that do what I do, that sit on the ERCP SIG committee, have been advocating for years and decades on trying to get an alternative, because we don't have one and these scopes are getting old, they're not serviced anymore by Olympus and very few are available. So that's a challenging fact.
Speaker 3:But going back to your question, you know size matters for us and so for ERCP our scope is a little bit more than 11 millimeters, and so we usually can use it in most children about 10 kilos or above. So obviously we have difficulties when kids are less than 10 kilos and for ERCP the scope is a little larger, close to 12, 13 millimeters, and it's a lot more rigid because of the electronics for the ultrasound, and so there kids have to be maybe 15 to 18 kilograms. So you can see that right there we're eliminating a good proportion of our patients or we are putting the scopes in patients that are quite tight fit, and so obviously that adds to the stress and potential complications. So I would say that most of the technical issues are related to the size of our patients. You know, fortunately, despite all that, in published data from our group in NASPEGEN and from others, our complication rates for ERCP and US are very comparable to experienced adults. So that's the good news.
Speaker 1:So it's interesting to know that there isn't a functioning scope for babies or kids under 10 kilos of weight. Can you speak more to, or what are the indications of EUS and ERCP would be in a baby, infant or a child less than 10 kilos?
Speaker 3:Yeah, believe it or not, some of these small kids may, especially with chronic illnesses, tpn, antibiotics or cardiac patients, may have stones in the common products and they may present with a colic, stools and obstructions. And we've had, I've had plenty of patients like that, and so of my colleagues. And so, in order to try to tackle that, we need, you know, a small scope, obviously, to put in these patients that are, you know, five kilos, four kilos, three kilos, and that's that's the only one we have, and very few of us have that scope, and we treat it like it was made out of glass, because if it breaks we don't know if we can repair it.
Speaker 1:So, like in the past, it was like stones are only common in certain population older kids or adults that have maybe high BMI or high cholesterol, but now it's becoming more common in babies and infants.
Speaker 3:Yeah, the other thing is you may not see it in the podcast, but I have quite a bit of gray hair already and so that I can tell you that, if you look at the past decade, goldstone disease is way more common in the past 10 years that I've ever seen it in pediatric patients. So I've had patients with goldstone disease that are, you know, 10 years old, nine years old and below, which is quite impressive and that just tells us probably about our changing lifestyle and environment, but it's definitely more prevalent than it was before.
Speaker 2:So my question to follow up on that has to do with why we don't have these made. Is this a cost issue, you know, like maybe we don't do them that's frequently, so these big companies like Olympus aren't wanting to make more or why do we think that they haven't been developed yet? Because clearly the technology is there and it's from the 90s, so you would think we would be able to do it a lot easier now.
Speaker 3:Yeah, so it's essentially economics, right. I mean a company that invests on R&D for a product. They're looking at the adult market why? Because the adult market does about, you know, 500 to 600,000 ERCPs per year. My group here at Stanford has looked through databases and we do about maybe 12 to 1500 ERCPs in pediatrics per year. So you can see the difference in market share and so for them it makes sense to focus on the adult market. I think what we've been trying to do and this has been a titanic effort by people before me and with me is trying to convince the companies that not only there's an ethical value in this, but there are some indications where adults would use a smaller diameter scope, and we've estimated that it's about maybe five to 7% of the total adult ERCPs. So hopefully with that it'll be enough market share for them to produce a scope that we can utilize for smaller patients in tenequilas.
Speaker 2:Yeah, I think that's a great strategy to take because you know you can't argue with economics but at the same time, if you have that patient who really needs it, we want to make sure that it's available for them. So you know, you talked a little bit about gallstones, but can you talk a little bit more about the common pancreatic obliary disorders that you diagnose and treat using EOS and ERCP?
Speaker 3:Sure, I mean I think that it's going to depend a little bit of where you are and what kind of patient populations you see. For me particularly, I work at Stanford. We have a very large pediatric liver transplant program and so my indications as far as billery come usually from transplant patients or either pre or post liver transplant patients, and I also see and take care of a lot of pancreatic patients that are referred to our pancreas center, and so there, you know, I end up doing. About 35 to 40% of my total ERCPs are pancreatic indications. So I think it depends of where you are and what kind of patient population you see.
Speaker 3:But I think in pediatrics we see the same kind of problems that they see in adults, but maybe different indications. So we see less malignancy and more congenital problems. We still see stones and strictures that we need to intervene on, and I think the gamut of EOS therapeutics has been growing on the adult side and obviously that's trickled down to pediatrics. So we do a lot of therapeutic EOS now in pediatrics. So not only diagnostic but therapeutic, and we see less pancreatic masses than the adults right, I mean adults. Eos people are doing hundreds, if not thousands, of pancreatic masses per year I probably do a dozen a year, so it's a very small amount. I do deal with complications, just pancreatic flu collections that we drain now almost exclusively endoscopically. So this is now a big change over the past I would say decade that we handle this not by surgery or IR but by endoscopy. So those are some of the common things that we see in pediatrics.
Speaker 2:So I have to go back to this baby scope idea again because I think about sorry, but I think about our XP scopes that we use in small infants and the channel is smaller, so we have less capability with a scope like that. So, this antique relic of a scope that you treat like glass, are you still able to do all of the interventions that you would want to do? When is that a potential challenge when it comes to developing a new, smaller scope?
Speaker 3:So yeah, I mean you're preaching to the choir, right? I mean, if you speak to any of my colleagues, they'll have the same issues. Yeah, so the channel of the small due denoscope is the same channel as the XP, so it's two millimeter, which in turn limits the type of accessories that we can put through that channel. And when it comes to ERCP, we essentially have five accessories that we can place through that channel. So there's one stent, one cannula, one basket, one Sphinxer Tome that is made by one company. So we are definitely limited. I think we can do most of the things or at least palliate the patient until we can tackle the patient when he or she's a little bit bigger. But yes, we're definitely limited by accessories because the same criteria or economic criteria that applies for pediatric scopes applies for pediatric accessories.
Speaker 1:So what are the primary advantages of using EOS or ERCP over imaging modalities for diagnosing pancreaticobiliary disorders in kids?
Speaker 3:So there's been many studies published adults and pediatrics that show that ERCP and US are superior to CT or MRI. Right Now. Ercp and rightly so has or is now mostly a therapeutic procedure because obviously it has complications, way more than doing imaging or EOS. And so we limit or we try to limit this for therapeutic indication, meaning we're tackling a stone, we're tackling a structure.
Speaker 3:But EOS is way more sensitive and specific than MRI and the whole reason of why EOS was created in the first place was to look at pancreatic masses and the first comparative studies and this is like in the 80s with MRI and CT will tell you that it's more sensitive and specific. And it's more sensitive and specific for any smaller structure. So anything less than two, three millimeters, the MRI may not pick up with great detail or not pick up at all, and the US will pick up and when it comes to something like chronic pancreatitis, for example, the changes that you see in the pancreas. So EOS is way more sensitive and specific than any of the imaging modalities. Obviously it's invasive because you have to give sedation, but in smaller patients you may have to sedate the patients anyway to do an MRI or a CT.
Speaker 1:So I just want to talk about kind of techniques of EOS. What are the challenges that you would face while you're doing an EOS that might kind of limit you from getting the images that you need.
Speaker 3:So in EOS we scan the patient on different stations right, usually it's at the G-junction, usually it's in the stomach, usually it's in the duodenum and then in the second portion of the duodenum around the papilla. So those are kind of the four stations that traditionally are used to scan everything that you want to scan within the abdomen using EOS. And so, again, it's mostly technical in size. So sometimes you may be able to get the scope through the or pharynx of a smaller patient and into the stomach, but it may not pass the pylorus or it may not pass the duodenal sweep, so you may have some limitations on where you can actually position the scope.
Speaker 3:If there's not a technical problem so it's a bigger patient, let's say a 25 kilogram patient, and you can pass the scope, then I think that there's less limitations because you can really scan the patient well, and if there's any therapeutics that need to be done, you can do them. That maybe either taking a sample when we talk about it, pedability, because that's most of the indications. But I will tell you that now that we have kind of an active endoscopy unit and everybody in the hospital knows what we can do, we get call 3, can we from, let's say ID, because they want us to biopsy lymph node of this patient, or oncology, because they want us to biopsy a mass in the metastinum or in the hyaline, which may be easier for us to do than IR coming from the outside and around the vessels.
Speaker 2:That's exactly what I was just thinking, because we had this discussion recently at my own or institution about when should people contact GI for these things like biopsies versus IR, which is where most people are trained, if they didn't have advanced endoscopy at their own site? And then I know this is kind of going backwards a little bit. But what about gas? Do you have any trouble with gas and using an ultrasound to visualize what you need to see?
Speaker 3:Usually not, because the ultrasound's position in the stomach, in the esophagus and the duodenum, and so usually we suction down everything because, as you mentioned, ultrasound doesn't travel well through air. As we suction down everything, usually we can get pretty good windows and we actually get better windows, in my view, in smaller kids than we do in larger kids with high BMI or even some adults.
Speaker 1:And another question anything kind of specific in preparation for EOS or ERCP that needs to be done to increase the quality of images or the ability to go into the sphincter other than the normal, the regular MPO times?
Speaker 3:No, just usually the MPO times. I mean, obviously there's some patients that may require specific indications or precautions, such as patients that have, let's say, sort of obstruction or delayed gastric emptying or things like that, but for the most part I would say, similar to doing a regular endoscopy. Going back to your statement, Jennifer, what we do now in our institution I suspect this happens in the other institutions is that when we have something that we want to take a sample on or biopsy, we usually discuss in radiology rounds with IR and we determine, OK, who do we think has a better access with less problems or less vessels or less things in between? And then we decide whether it's IR or us. And so that's how we've been doing it, and I think that's probably the way forward is really to discuss to see who's going to be more successful or have less of an issue getting to where we need to get to to obtain a biopsy or a sample.
Speaker 2:I love that. I love that multi-disciplinary care approach so that we can make sure that we're doing what's safest for the patient. You previously mentioned about chronic pancreatitis and I wanted to just touch on that a minute because you said that it was. The images that you can get can be a little bit more sensitive than, say, an MRI, and currently with our kids with chronic pancreatitis, my understanding is we typically repeat that imaging every year, but I don't know of any protocol as far as how frequently they should be getting EUS. How should we be approaching that?
Speaker 3:Yeah, it's a very good question, so I'll make a plug here. So in 2020, the Pancras and Endoscopy Committee published some guidelines for chronic pancreatitis and the use of EUS and ERCP.
Speaker 2:Whoops, I must have missed that one, it's okay.
Speaker 3:And you know, the guidelines were based on expert opinion, which means a bunch of people like myself with gray hair, right, but that also means that there's no data in pediatrics, and that's unfortunate, and I think we're trying to remedy that by collaborating, because I think in pediatrics, with our lower volume, the only way forward is really to collaborate within centers, instead of saying, oh, here are 30 kids from here and 50 kids from there, and so I think it's better to collaborate, but, going back to that, there's no guidelines.
Speaker 3:And then some of the criteria that are used, for example, in EUS for chronic pancreatitis, were all developed on adult patients, and whether that's translatable into pediatrics really remains to be seen, and so I think we really need data to answer some of those questions. Until then, you have the second best, which is so-called expert opinion and some guidelines. I'm hoping that the next guidelines hopefully in the next five years or something to follow up these 2020 guidelines we'll have some more data to really put forward and have recommendation based on real data. So we don't have the answer to that, jennifer. I'm sorry, jennifer.
Speaker 2:I'm sorry, notice yourself. Put that on the PubMed ping when Dr Cookeag and et al Put these new guidelines out with data.
Speaker 3:Well, I think this is also since a lot of people listen to the podcast. There's fellows or other people interested in adopting. This is an area that we require help with, so let's collaborate.
Speaker 2:Oh, that is so true. I think I was just thinking about a patient I was taking care of recently where had some imaging findings that could be consistent with chronic pancreatitis, but then clinically was not exactly fitting, and so I think having additional data would be so helpful in situations like that.
Speaker 3:Well, the difficulty also is let me just give you a brief history of how these criteria came up in adults. So in like 2007, 2008, 32 specialists or experts from adults convene in Rosemont, illinois, so that's why the criteria is called the Rosemont criteria and they developed this criteria that were based on parenchymal criteria and ductile criteria and they divide into major, minor criteria. I'm not going to go through the whole thing, but they developed this criteria and then they started looking at it and validating it and so a couple of things. I mean there's definitely inter and intra observer variability, so that's important to note.
Speaker 3:And the other thing is I think ultrasound is very good at looking at completely normal pancreas and a really bad chronic pancreatitis pancreas. The in between is where we have issues, right, and so we've tried to see if we can pick up early quote unquote chronic pancreatitis. And so there's there actually has been some functional US studies, both adult and pediatrics, in where you would give secretin and do the US study and you would measure the difference in the diameter of the pancreatic duct. And in some studies they've actually added a pancreatic stimulation test because you're giving secretin in that test. So you put you do a pancreatic stimulation test you do the difference in duct diameter with and without secretin and that seems to be actually better at predicting early chronic pancreatitis. So, yes, I think there's still a lot of work to do and again, I think this is something to that we need help with many different centers to collaborate and hopefully have some some real data for the future.
Speaker 1:You ask a little bit more about that US secretin early diagnosis of pancreatitis or chronic pancreatitis. What is the diameter difference? Do you see increase in diameter, decrease in diameter?
Speaker 3:Yeah, you should see an increase in diameter after giving secretin and you should see at least a millimeter increase in diameter. And they measure the pancreatic duct at different areas of the pancreas and they take three measurements it was a whole protocol and then, in conjunction with the pancreas stimulation test and bicarbonate level, besides the pancreatic enzymes they measure bicarbonate level. So with all that together I think we're a lot better. Certainly it's more invasive than doing MRI and there's also been some functional MRI testing. There's been some studies published from Cincinnati Children's and their group and using secretin MRI and determining, based on the amount of output in the duodenum after the secretin, whether they consider the pancreas function normal or not. And so, yeah, I think that there's there's slowly some new technology, some new data, some new applications that may give us some additional information than just the US alone.
Speaker 1:That's very exciting New data, new studies. It's always very exciting. I do want to ask you about when you do an EOS and ERCP, what do you use to assess the severity, to determine chronic pancreatitis and assess the severity of it? What findings key findings do you look for?
Speaker 3:So I look at the you know parenchyma and the duct and then I see if the parenchyma is normal or not. Again, that's a quantification right. I mean, we don't have all the data, but we're trying to generate data of what normal parenchyma mass is in different age groups. So what does the parenchyma mass look like? What does the parenchyma itself look like? Is it homogeneous, is it not? Does it have any stranding, any evidence of calcifications? And the same. The duct is it normal? Is it tortuous? Can you see side branches of the walls of the duct normal? And, of course, the diameter, because once you start seeing chronic pancreatitis, you can you start seeing that the pancreatic duct slowly becomes dilated and tortuous.
Speaker 1:I guess my other question is do you ever consider biopsy?
Speaker 3:Not for chronic pancreatitis, at least routinely I think Dr Sellers and myself, who work here and see the majority of the pancreas patients, we consider biopsy in patients that we suspect autoimmune pancreatitis, and before the biopsies that we obtained were not as helpful because we were using FNA needles and then pathology would really have a difficult time committing to us whether this was autoimmune pancreatitis or not. But now that we're using FNB needles, which give us a lot more tissue, we've actually had a lot more information and pathologies more willing to commit to us with this patients, autoimmune pancreatitis or not.
Speaker 2:That's fascinating. So I want to go back to this discussion about complications, because you previously mentioned that the data do not show that pediatric patients have higher complication rates, despite having smaller everything. But can you walk us through what are common complications when you're doing some of these advanced techniques and what about things that can be done to minimize this? As far as post-ERCP antibiotics, for example, will you walk us through some of that post-procedure?
Speaker 3:Sure, so I'll first clarification. So one of the, I think, good things that has been done by NASPAN, specifically led by Dave Trindell at UT Southwestern, has been our PDERCP database and from that PDERCP database, where 14 hospitals participated 12 from the US and two from outside the US all these ERCP cases were put in this database via RedCap. We've obtained a lot of information, including the complications. So one caveat that we'll make is that kids that are less than two years of age that undergo an ERCP have a little bit higher complication rates than kids that are above two years old. So that's the first caveat that I would make.
Speaker 3:But in general, for ERCP the complications are well known and well published. Post-ercp pancreatitis is the most common one. For a specific billary indication meaning you're not on purpose going into the pancreatic duct it should be between 3 and 5% in most cases. If you're doing pancreatic interventions it can be higher, up to 7 to 10% and in kids that are less than two years old it can be higher than the 3 to 5%. The other complications, such as for ERCP we're talking about, like bleeding and perforation and infection, are usually less than 1%. As far as mitigating this, there's a variety of technical ways that we try to mitigate this. While doing any ERCP it's been correlated with the size of the synchrotone, with the number of attempts in the papilla, with how complex the procedure is or not. So there's a variety of technical ways we try to mitigate.
Speaker 3:Fluid has been used to treat acute pancreatitis but also to mitigate some of the post-ERCP pancreatitis. So giving fluids at about one and a half maintenance if possible, if the kid tolerates it seems to mitigate and help. And then anti-inflammatory agents such as endomethazone and even others that have been researched, given around the time of the ERCP, can mitigate the post-ERCP pancreatitis. I will confess that some of my colleagues use endomethazone for every single ERCP and I don't.
Speaker 3:I don't know if I'm right or if I'm wrong. We track both adults and pediatric. It's time for ERCP prospectively and I don't seem to have a different rate of post-ERCP benignctitis not using in the methods for every single patient, even though my adult colleague use it for every single patient and some of my pediatric colleagues use it for every single patient. So I'm not sure if I'm right or wrong, but that's definitely for high-risk patients. It's something that would help. For EUS. There's been complication rates quoted in 1% or 2%, including pancreatitis, if you do a biopsy of the pancreas, but the complication rates have been usually less than 1% or 2% for EUS, even for interventional EUS where you're putting stents in, et cetera.
Speaker 1:I have a couple of follow-up questions on that. Can you elaborate a little bit more about what the techniques you do or use to reduce the complications with ERCP and for endomethacin? Do you use IV or rectal or oral, and what are your indications for using it?
Speaker 3:Yes, so I'll answer the endomethacin question first. Usually we use rectal endomethacin and we've developed a weight-based scale for patients. Some other medications have been used IV. Some other non-inflammatory agents have been used IV. And as far as technically, what I do is I don't have fellows doing ERCPs with me, so I do all the ERCPs, but that's an important consideration.
Speaker 3:When I was training I was given a certain amount of time, like with a kitchen clock, to cannulate and when the clock rang they took the scope away. That's it, ok, wow. Well, because and this is because the number of times, the number of attempts that you make to that papilla makes a difference. So the more attempts, the more swelling you get in the papilla and the more rate of post-ERCP pancreatitis. I usually use tapered tomes with a dome tip. I tend to use smaller tomes and smaller guide wires than we normally use on adults. And as far as technique, specifically, both my adult colleagues at Stanford and myself, if we do three tries and we're not able to cannulate the desired duct, we're already thinking about doing a different access technique. So not only using a sphincter tone, but maybe pre-cut or fished, a lot of me, et cetera, which are different techniques, rather than persisting with the same technique. We consider, after three tries, going to a different technique. Yeah, so those are some of the things that we use normally.
Speaker 2:Thinking about this kitchen timer, I feel like it increases the pressure just in general.
Speaker 3:It was very stressful, but I had it both for my ERCP and for EUS training for two different reasons. So for the ERCP obviously was trying to prevent excessive manipulation into the papilla. For the EUS, it's because where I train in EUS I used to do 12 EUS in the morning, 12 EUS in the afternoon, so we didn't have a lot of time and so they gave me only four minutes to scan and tell them the diagnosis, and it was by a clock because they didn't have time for me to spend 20 minutes scanning the patient. So yes, they use that on the adult. It is very stressful. I've never seen on the pediatric side.
Speaker 1:Do you have nightmares of like a kitchen clock running after you and ding, ding?
Speaker 2:I was thinking like is it like a little egg? Or you know how they have the cutesy ones these days.
Speaker 3:Yeah, it wasn't very cute, but it was very stressful because you can hear it ticking.
Speaker 1:Oh, ticking Whoa.
Speaker 3:You can hear the tick and then you can glance at it and you see how it's coming less and less closer to the zero, that's so funny.
Speaker 1:The next question is are there any long term side effects, Not just immediate Long term side effects of EUS or ERCP?
Speaker 3:Yeah, I think when it comes to ERCP, the issue I would focus more is on fluoroscopy right. We use fluoroscopy. We have very small patients that are growing, which means they have very high cell turnover, so we have to be really cognizant about how much we use fluoroscopy. We need to take a lot of care and this is something that we in the ERCP, sig and with the PD-ERCP database have published on right I mean fluoroscopy safety. I think it's extremely important for us because this can have long term consequences. I'm not aware of a big cohort of patients from the pediatric side that I've had ERCP and then are followed I don't know 25, 30 years later to see what kind of difference we see on the ones that have had fluoroscopy or more fluoroscopy time.
Speaker 2:So a quick question when we talk about this egg timer which of course I'm still on, no, I just want to talk about what factors make a successful intervention right. So with colonoscopies, we think about how often are you actually getting into the terminal Ilium, for example, and completing the entire assessment, can you talk about the success rate for these techniques and what can be done to optimize pediatric outcomes?
Speaker 3:Yes, I think that adults have been very good at developing quality parameters for each of the endoscopic procedures, including EUS and ERCP, and I think that competency in ERCP is defined as cannulation of the desired duct 90% of the time.
Speaker 3:So I think that you have to be competent doing these procedures, and that comes with training volume and experience, and so I think that it's no different than any other procedure. We need to be sure that the procedures are performed by people that are properly trained and have experience. As a parentheses, by the way, we don't have any guidelines on how to train a pediatrician to be in advanced endoscopies. There are guidelines on the adult side. We don't have any in pediatrics and, like I said at the beginning, many of us have been trained through different routes, and so this is something that we definitely need to work on, because I think it's extremely important if we want to take care of quality in pediatrics, and this all starts with how we train people in doing these procedures. So, again, there's a lot of things that we need data on, and this is one of them, jennifer.
Speaker 1:And that's a great segue to our next question. It looks like there's a lot of information to be gathered for pediatric EOS and ERCPs and there's a lot of opportunity for research. So what are the ongoing research that is being conducted to improve the use of EOS and ERCP in pediatric patients, and when advances into technology or techniques are on the horizon?
Speaker 3:Yes, I think, like I said before, and I really maintain this in pediatrics, if we really want to advance a field of advanced endoscopy, we need to collaborate, just because only one center will now have enough volume to really produce robust data. And so I think the PD-ERCP database is really important. It's ongoing and we're trying to set up a PD-EOS database as well so we can input patients and collaborate. I think multi-hospital collaborations are extremely important to really gather data that is meaningful, because I think the days of publishing this hospital's experience, or that group's experience, I think, is, I mean, it may be great for the ego, but it really doesn't advance the field as it should be, and so I think that it still is a working progress. But I'm not that discouraged because I think there's really eagerness to do this.
Speaker 3:And just going back to adults, ercp has been around for more than 50 years and I tell you that a simple question that has been asked for in adults, which is doesn't early ERCP need to be done in somebody who comes in with galsum pancreatitis? That's a very common question, right? And is that beneficial for the patient? Well, it took decades and decades of study, and it was only until very recently, a few years ago when the Dutch pancreatitis group published their data where it showed that early ERCP, excluding patients that had active colonitis, was not necessary or beneficial for galsum pancreatitis. So I mean, it takes decades. Right, some things take decades, but it's only through collaboration and Dutch pancreatitis group. They really collaborate because they have the whole of the country collaborating together in gathering data and producing meaningful data. So I think this is the same model that we should be using in pediatrics. Hopefully it doesn't take us as many decades.
Speaker 1:Absolutely Everybody should reach out to you with new ideas, Join the collaborative, Join the SIG and hopefully Olympus or another company listens to the request of having a scope, ERCP, US scope for babies.
Speaker 2:Absolutely, I agree. So, dr Googie, thank you so much for spending time with us. We just have a couple last questions, and this is a newer one that we've put out there. So we've talked about so many things today, but for the listeners who may have skipped past all of that and only want to hear the top three takeaways, what would be your main key points from the discussion?
Speaker 3:I think we now have well-trained pediatric advanced endoscopists that are able to do these procedures safely. We need to collaborate together to produce data for all of us to know how to better treat our patients, and we really need better dedicated equipment for pediatrics.
Speaker 1:Right, yeah, those are very important takeaways, so if you've ever skipped, you should probably go back and listen to the whole podcast. Thank you very much for joining us Now. Our last question is if you look back at your career, what do you think was the most valuable advice that somebody gave you, and what advice do you have for our listeners?
Speaker 3:I'm going to say something probably unexpected for you. I'm going to say be kind to one another. I think when I was training through residency and fellowship, you meet a lot of attendings in your path, in your way, and some people are great and some people are awful, and hopefully you can take the good things of the people that you meet and imitate them and not repeat the bad things that you're exposed to. And I think kindness is underrated. We should be kinder to one another. So that's what I would say.
Speaker 1:And kind to your patience too, because everybody's going through something. Absolutely, that's great advice. That's great advice. Thank you very much for joining us today. This was a great discussion.
Speaker 2:This was a lot of fun. It was great to meet you.
Speaker 3:Let's do this again.
Speaker 1:Yes, yes and for everybody you can talk about poem next time.
Speaker 2:Ooh, that's a great topic. Thank you very much, but you have to give a poem first.
Speaker 1:You have to write a poem, and write it and then say it on the podcast, and then we talk about the podcast to the scope.
Speaker 2:What a great episode. Talking to Dr Kugik Tamara, I totally see why you were so taken by him at this junior fellow conference. Yes and wait, not junior fellow junior faculty conference.
Speaker 1:Yes, junior faculty conference. And I keep on laughing every time I remember this big kitchen timer Like me. Yes, I'm having dreams about like a kitchen timer running after him and he's like running. I made that up, but that would be a very funny dream, right, oh man so much anxiety.
Speaker 2:Anyway, hey, if you don't already, be sure to follow us on Twitter and Instagram, at at Bell Sounds, and on Facebook and at pediatric GI podcast for the latest news and updates on upcoming episodes.
Speaker 1:If you like what you heard and want to support the podcast. It would really help us out if you did one or all of the following three things One, tell one person, two persons, three persons, 10 persons about the podcast to leave a review on Apple podcast to help others discover our podcast. And three on our bus route page there's a link to support the show by making a donation to the Naspigan Foundation. You can also get there through wwwnaspiganorg. The money you donate helps support some of the amazing things the Naspigan Foundation is doing, including supporting pediatric GI research and public education programs. As always, the discussion, views and recommendations of the podcast are the sole responsibility of the hosts and guests and are subject to changes with advances in the field. What she said.
Speaker 2:Anyway, thanks for listening. I was still muted talking out loud to myself. Thanks for listening all until next time. Until next time Bye.