Roberto Gugig

All Publications

• Initial Experience with Duodenoscopes with Single-Use End Caps in Pediatric Endoscopic Retrograde Cholangiopancreatography: Infection Prevention Comes at a Cost. Gastrointestinal endoscopy Barakat, M. T., Liman, A., Gugig, R. 2024

  Abstract

  BACKGROUND AND AIMS: Duodenoscopes with single-use end caps were introduced to minimize infection risk, but are unstudied in pediatrics.METHODS: We collected clinical data and endoscopists' evaluations of duodenoscopes with single-use end caps versus reusable duodenoscopes over 18 months.RESULTS: A total of 106 ERCPs were performed for patients aged 1-18 (mean 14.2) years. Forty-six involved single-use end caps, with 9 requiring crossover to reusable duodenoscopes. ERCPs involving single-use end caps resulted in more instances of mucosal trauma (10 vs 0, p<0.05) and post-ERCP pancreatitis (4 vs 1, p<0.05), and accounted for 8 of 9 ERCPs requiring advanced cannulation techniques. No post-ERCP infections occurred. Reported challenges included single-use end cap stiffness and difficulty with their alignment for cannulation.CONCLUSIONS: We report difficulty with advancement, greater reliance on advanced cannulation techniques, and higher rates of PEP when using duodenoscopes with single-use end caps in pediatric ERCP. This area warrants further study.

  View details for DOI 10.1016/j.gie.2024.03.009

  View details for PubMedID 38462055

• Pediatric ERCP: Evolving into an Outpatient Procedure. Digestive diseases and sciences Barakat, M. T., Liman, A. Y., Gugig, R. 2024

  Abstract

  While most adult ERCPs are performed on an outpatient basis, pediatric ERCPs are typically performed on an inpatient basis, or with ERCP followed by at least one night inpatient admission. We have begun performing a substantial proportion of our pediatric ERCPs on an outpatient basis, using our clinical judgment to guide the decision process. In the present study, we compare patient characteristics, indications, and adverse events associated with outpatient vs. inpatient ERCP.Using our endoscopy database, we identified patients 18 years of age and under who underwent ERCP from 2019 to 2021. Demographics, hospitalization status, indications, findings, interventions, as well as available adverse event and clinical outcomes data were analyzed.147 ERCP procedures were performed during the study period by one of two interventional endoscopists. A subset of 51 (34.7%) patients underwent outpatient ERCP. Comparison of the two groups (outpatient vs. inpatient ERCP) was notable for no statistically significant difference in patient age, range of indications, or proportion of index vs. subsequent ERCP. Overall rates of ERCP-associated adverse events were low and there was no statistically significant difference between adverse events in patients who underwent outpatient vs. inpatient ERCP.We analyzed outpatient and inpatient pediatric ERCP patient demographics and ERCP characteristics to identify factors that guide decision to determine whether pediatric ERCPs are performed on an outpatient vs. inpatient basis. There was no significant difference in adverse events associated with outpatient vs. inpatient pediatric ERCPs, attesting to the safety of outpatient ERCP for this subset of patients in the studied context. This is an area worthy of future prospective and multi-center study.

  View details for DOI 10.1007/s10620-024-08325-9

  View details for PubMedID 38418682

  View details for PubMedCentralID 1412491

• Esophageal lung, pulmonary artery sling and congenital tracheal stenosis: A case report JOURNAL OF PEDIATRIC SURGERY CASE REPORTS Liang, N. E., Kim, G. S., Gugig, R., Ma, M., Coll, A., Sidell, D., Bruzoni, M. 2024; 101

  View details for DOI 10.1016/j.epsc.2023.102772

  View details for Web of Science ID 001154609300001

• ENDOSCOPIC ULTRASOUND-PANCREATIC RENDEZVOUS CAN BE SAFELY AND EFFECTIVELY PERFORMED IN PEDIATRIC PATIENTS WHEN PANCREATIC INTERVENTION IS NOT POSSIBLE WITH STANDARD ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Barakat, M., Liman, A., Gugig, R. MOSBY-ELSEVIER. 2023: AB1187

  View details for Web of Science ID 001038022802580

• Endoscopy and Pediatric Pancreatitis. Gastrointestinal endoscopy clinics of North America Grover, A. S., Gugig, R., Barakat, M. T. 2023; 33 (2): 363-378

  Abstract

  Children and adolescents are increasingly impacted by pancreatic disease. Interventional endoscopic procedures, including endoscopic retrograde cholangiopancreatography) and endoscopic ultrasonography, are integral to the diagnosis and management of many pancreatic diseases in the adult population. In the past decade, pediatric interventional endoscopic procedures have become more widely available, with invasive surgical procedures now being replaced by safer and less disruptive endoscopic interventions.

  View details for DOI 10.1016/j.giec.2022.11.002

  View details for PubMedID 36948751

• IMPACT OF TRAINEE INVOLVEMENT ON PEDIATRIC ERCP PROCEDURES: RESULTS FROM THE PEDIATRIC ERCP INITIATIVE. Journal of pediatric gastroenterology and nutrition Gupta, R., Khalaf, R., Morrison, J., Amankwah, E., Ruan, W., Fishman, D. S., Barth, B. A., Liu, Q. Y., Giefer, M., Kim, K. M., Martinez, M., Dall'oglio, L., Torroni, F., De Angelis, P., Faraci, S., Bitton, S., Dua, K., Werlin, S., Gugig, R., Huang, C., Mamula, P., Quiros, J. A., Zheng, Y., Piester, T., Grover, A., Fox, V. L., Wilsey, M., Troendle, D. M. 2023

  Abstract

  This study examines the role of trainee involvement with pediatric endoscopic retrograde cholangiopancreatography (ERCP) and whether it affects the procedure's success, post-procedural adverse outcomes, and duration. A secondary analysis of the Pediatric ERCP Database Initiative (PEDI), an international database, was performed. Consecutive ERCPs on children <19 years of age from 18 centers were entered prospectively into the database. In total 1124 ERCPs were entered into the database, of which 320 (28%) were performed by trainees. The results showed that the presence of trainees did not impact technical success (p=.65) or adverse events rates (p=.43). Rates of post-ERCP pancreatitis, pain, and bleeding were similar between groups (p >.05). Fewer cases involving trainees were in the top quartile (>58min.) of procedural time (19% vs. 26%; p=.02). Overall, our findings indicate trainee involvement in pediatric ERCP is safe.

  View details for DOI 10.1097/MPG.0000000000003782

  View details for PubMedID 36976177

• Case Series of Precision Delivery of Methylprednisolone in Pediatric Inflammatory Bowel Disease: Feasibility, Clinical Outcomes, and Identification of a Vasculitic Transcriptional Program. Journal of clinical medicine Levitte, S., Yarani, R., Ganguly, A., Martin, L., Gubatan, J., Nadel, H. R., Franc, B., Gugig, R., Syed, A., Goyal, A., Park, K. T., Thakor, A. S. 2023; 12 (6)

  Abstract

  Systemic steroid exposure, while useful for the treatment of acute flares in inflammatory bowel disease (IBD), is associated with an array of side effects that are particularly significant in children. Technical advancements have enabled locoregional intraarterial steroid delivery directly into specific segments of the gastrointestinal tract, thereby maximizing tissue concentration while limiting systemic exposure. We investigated the feasibility of intraarterial steroid administration into the bowel in a cohort of nine pediatric patients who had IBD. This treatment approach provided symptom relief in all patients, with sustained relief (>2 weeks) in seven out of nine; no serious adverse effects occurred in any patient. In addition, we identified patterns of vascular morphologic changes indicative of a vasculopathy within the mesenteric circulation of inflamed segments of the bowel in pediatric patients with Crohn's disease, which correlated with disease activity. An analysis of publicly available transcriptomic studies identified vasculitis-associated molecular pathways activated in the endothelial cells of patients with active Crohn's disease, suggesting a possible shared transcriptional program between vasculitis and IBD. Intraarterial corticosteroid treatment is safe and has the potential to be widely accepted as a locoregional approach for therapy delivery directly into the bowel; however, this approach still warrants further consideration as a short-term "bridge" between therapy transitions for symptomatic IBD patients with refractory disease, as part of a broader steroid-minimizing treatment strategy.

  View details for DOI 10.3390/jcm12062386

  View details for PubMedID 36983386

• Pediatric ERCP in the Setting of Acute Pancreatitis: A Secondary Analysis of an International Multicenter Cohort Study. Journal of pediatric gastroenterology and nutrition Trocchia, C., Khalaf, R., Amankwah, E., Ruan, W., Fishman, D. S., Barth, B. A., Liu, Q. Y., Giefer, M., Kim, K. M., Martinez, M., Dall'oglio, L., Torroni, F., De Angelis, P., Faraci, S., Bitton, S., Werlin, S., Dua, K., Gugig, R., Huang, C., Mamula, P., Quiros, J. A., Zheng, Y., Piester, T., Grover, A., Fox, V. L., Wilsey, M., Troendle, D. M. 2023

  Abstract

  Previous studies have demonstrated the safety of performing Endoscopic Retrograde Cholangiopancreatography (ERCP) in the pediatric population; however, few have addressed the outcomes of children undergoing ERCP during acute pancreatitis (AP). We hypothesize that ERCP performed in the setting of AP can be executed with similar technical success and adverse event profiles to those in pediatric patients without pancreatitis. Using the Pediatric ERCP Database Initiative, a multi-national and multi-institutional prospectively collected dataset, we analyzed 1124 ERCPs. One hundred and ninety-four (17%) of these procedures were performed in the setting of AP. There were no difference in the procedure success rate, procedure time, cannulation time, fluoroscopy time or American Society of Anesthesiology class despite patients with AP having higher ASGE difficulty grading scores. This study suggests that ERCP can be safely and efficiently performed in pediatric patients with AP when appropriately indicated.

  View details for DOI 10.1097/MPG.0000000000003762

  View details for PubMedID 36913706

• The Majority of Patients Who Undergo ERCP When Large Duct Obstruction Is Evident on Liver Biopsy Have Biliary Findings Amenable to Endoscopic Intervention. Journal of clinical medicine Martin, M., Lee, J., Gugig, R., Ofosu, A., Charville, G. W., Barakat, M. T. 2023; 12 (2)

  Abstract

  (1) Background: Abnormal liver function tests are commonly encountered in clinical practice, often leading to additional workup to determine the underlying etiology of these abnormal laboratory studies. As part of this evaluation, if less invasive imaging studies are performed and are without evidence of biliary obstruction, liver biopsy may be performed, and the finding of large duct obstruction on liver biopsy is commonly encountered. The utility of endoscopic retrograde cholangiopancreatography (ERCP) for evaluation and management of possible biliary obstruction in patients with large duct obstruction on liver biopsy has not been studied to date. (2) Methods: To assess the utility of ERCP in patients with large bile duct obstruction on liver biopsy, we retrospectively evaluated patients with large duct obstruction on liver biopsy from 2010-2019 at our tertiary care and transplant center. Demographic and clinical characteristics were evaluated for all patients, with sub-group analysis for patients who underwent ERCP and those who had intervenable findings at the time of ERCP. Descriptive statistics with proportions, means, and standard deviations were performed for demographics and clinical variables using absolute standardized difference. (3) Results: During the study period, 189 liver biopsies with evidence of large duct obstruction were performed. After exclusion criteria were applied, 166 unique patients were eligible for the study. Ninety-one patients with evidence of large duct obstruction on liver biopsy underwent ERCP and 75 did not. Of the 91 patients who underwent ERCP, 76 patients (84%) had an intervenable finding at ERCP. Patients who underwent ERCP were overall more likely to have had a liver transplant (65% ASD 0.63), have previously undergone cholecystectomy (80%, ASD 0.56), and be immunocompromised (80%, ASD 0.56). (4) Conclusions: ERCP is high yield when large duct obstruction is apparent on liver biopsy, with the majority of patients (84%) who undergo ERCP in this clinical context having a biliary finding necessitating therapeutic endoscopic intervention.

  View details for DOI 10.3390/jcm12020482

  View details for PubMedID 36675410

• Pancreatic Fluid Leak Causing Mediastinal Shift JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Herdes, R. E., Syed, A. B., Gugig, R. 2023; 76 (1): E20

  View details for Web of Science ID 000904824600023

• Safety and efficacy of minor papillotomy in children and adolescents with pancreas divisum. Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.] Barakat, M. T., Husain, S. Z., Gugig, R. 2022

  Abstract

  INTRODUCTION: Pancreas Divisum (PD) is a common pancreatic ductal variant which is twice as common in pediatric patients with acute recurrent pancreatitis (ARP) relative to the general population (14% vs. 7%). Endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy has been performed to facilitate drainage of pancreatic juice from the diminutive minor papilla to prevent pancreatitis and pancreatic damage.METHODS: We searched our prospectively-maintained endoscopy databases for patients 18 and younger who underwent ERCP with minor papillotomy between 2009 and 2019. Demographic data, indications, procedural interventions and findings, as well as available clinical outcomes data were analyzed.RESULTS: 54 ARP/PD patients underwent ERCP with minor papillotomy. Median age was 14 (range 7-18) years, and 26 (48.1%) patients were female. Post-ERCP pancreatitis developed in 10/54 patients (18.5%). 12-month post-ERCP clinical trajectory was available in 47/54 (87%) patients and most patients (38/47, 80.8%) improved clinically after minor papillotomy, with 9/47 (19.1%) experiencing resolution of pancreatitis episodes and none indicated worsening severity or frequency of pancreatitis episodes following ERCP.CONCLUSION: The majority of children and adolescents with PD and ARP who underwent ERCP with minor papillotomy experienced subjective improvement in their symptoms following the intervention. These data suggest that ERCP with minor papillotomy for pediatric patients with PD and ARP is beneficial and may be curative in a subset of patients-higher rates of improvement than have been previously reported in adults.

  View details for DOI 10.1016/j.pan.2022.12.009

  View details for PubMedID 36641286

• Pancreatic Fluid Leak Causing Mediastinal Shift. Journal of pediatric gastroenterology and nutrition Herdes, R. E., Syed, A. B., Gugig, R. 2022

  View details for DOI 10.1097/MPG.0000000000003640

  View details for PubMedID 36245077

• Pediatric Endoscopy Blocks: Enhanced Efficiency and Endoscopist Satisfaction. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Pei, F., Gugig, R. 2022

  Abstract

  INTRODUCTION: Endoscopic procedures are increasingly performed for children and adolescents and these interventions represent a central element of both pediatric gastroenterology (GI) care and revenues. It remains unclear, however, which scheduling paradigm maximizes efficiency of resource utilization and delivery of care in this arena. In this study, we evaluate the impact of shifting from shared endoscopy blocks to individual, provider-specific endoscopy blocks for scheduling endoscopic procedures in our tertiary care academic center.METHODS: The implemented endoscopy block system involves a single endoscopist performing procedures in an allocated room for the entire day period of time, with most providers having 1-3 day blocks per month. We analyzed block fragmentation (multiple providers in a single block), block utilization and procedure volume, comparing the 8-month period prior to implementation of the block system (pre-implementation period) with the 8-month period following implementation of the block system (post-implementation period). Provider satisfaction and perceptions were assessed by survey pre- and post-implementation. Standard descriptive statistics were utilized for analysis.RESULTS: In the pre- and post-implementation periods, 22 half-day blocks were allocated to pediatric GI. In the pre-implementation period, mean utilization of these blocks was 65.9% (range: 47%-77%). In the post-implementation period, mean % utilization was 79.8% (range: 64%-89%). Overall endoscopy procedure volume increased from 279 in the pre-implementation period to 419 in the post-implementation period. Provider perception of endoscopy efficiency was enhanced by the block system, with 68.4% of pediatric GI respondents rating endoscopy as 'efficient' post-implementation (vs. 19% pre-implementation) and 63.2% indicating that the block system directly enhanced efficiency. 63.2% reported increased personal procedure volume and 84.2% reported perceived increase in overall procedure volume with block system implementation.CONCLUSIONS: Strategic approaches for scheduling endoscopic procedures carry the potential to enhance efficiency and experience for both providers and patients. Implementation of the endoscopy block system was associated with increased procedure volumes and block utilization as well as a more positive experience for the majority of providers. Schedule adjustments with analysis of associated efficiency and satisfaction metrics can optimize pediatric endoscopy practice.

  View details for DOI 10.1097/MPG.0000000000003624

  View details for PubMedID 36123768

• Technical Outcomes in Pediatric Endoscopic Retrograde Cholangiopancreatography: Data from an International Collaborative. Journal of pediatric gastroenterology and nutrition Troendle, D. M., Ruan, W., Fishman, D. S., Barth, B. A., Liu, Q. Y., Giefer, M., Kim, K. M., Martinez, M., Dall'oglio, L., Torroni, F., De Angelis, P., Faraci, S., Bitton, S., Wilsey, M., Khalaf, R., Werlin, S., Dua, K., Gugig, R., Huang, C., Mamula, P., Quiros, J. A., Zheng, Y., Grover, A., Fox, V. L. 2022

  Abstract

  OBJECTIVES: Endoscopic Retrograde Cholangiopancreatography (ERCP) in adults has been extensively studied through multicenter prospective studies. Similar pediatric studies are lacking. The Pediatric ERCP Database Initiative (PEDI) is a multicenter collaborative aiming to evaluate the indications and technical outcomes in pediatric ERCPs.METHODS: In this prospective cohort study, data was recorded for pediatric ERCPs performed across 15 centers. A pre-procedure, procedure, 2-week post-procedure follow-up, and adverse event form were completed for each ERCP performed. Univariate and stepwise linear regression was performed to identify factors associated with technically successful procedures and adverse events.RESULTS: A total of 1124 ERCPs were performed on 857 patients from 5/1/2014 to 5/1/2018. The median age was 13.5 years (IQR 9.0-15.7). Procedures were technically successful in the majority of cases (90.5%) with success more commonly encountered for procedures with biliary indications (OR 4.2) and less commonly encountered for native papilla anatomy (OR 0.4) and in children < 3 years (OR 0.3). Cannulation was more often successful with biliary cannulation (95.9%) compared to pancreatic cannulation via the major papilla (89.6%, p<0.0001) or minor papilla (71.2%, p<0.0005). The most commonly identified adverse events included post-ERCP pancreatitis (5%), pain not related to post-ERCP pancreatitis (1.8%), and bleeding (1.2%). Risk factors for the development of each where identified.CONCLUSIONS: This large prospective study demonstrates that ERCP is reliable and safe in the pediatric population. It highlights the utility of PEDI in evaluating the technical outcomes of pediatric ERCPs and demonstrates the potential of PEDI for future studies in pediatric ERCPs.

  View details for DOI 10.1097/MPG.0000000000003612

  View details for PubMedID 36122368

• Technological imbalance: Seeking a small-caliber duodenoscope. Gastrointestinal endoscopy Lin, T. K., Barth, B., Fishman, D. S., Fox, V. L., Giefer, M. J., Gugig, R., Kramer, R. E., Liu, Q. Y., Mamula, P., McOmber, M. E., Vitale, D. S., Wilsey, M. J., Troendle, D. M. 2022

  View details for DOI 10.1016/j.gie.2022.08.025

  View details for PubMedID 36007585

• Advances in Pediatric Diagnostic Endoscopy: A State-of-the-Art Review. JPGN reports Lerner, D. G., Mencin, A., Novak, I., Huang, C., Ng, K., Lirio, R. A., Khlevner, J., Utterson, E. C., Harris, B. R., Pitman, R. T., Mir, S., Gugig, R., Walsh, C. M., Fishman, D. 2022; 3 (3): e224

  Abstract

  Pediatric endoscopy has revolutionized the way we diagnose and treat gastrointestinal disorders in children. Technological advances in computer processing and imaging continue to affect endoscopic equipment and advance diagnostic tools for pediatric endoscopy. Although commonly used by adult gastroenterologists, modalities, such as endomicroscopy, image-enhanced endoscopy, and impedance planimetry, are not routinely used in pediatric gastroenterology. This state-of-the-art review describes advances in diagnostic modalities, including image-enhanced endoscopy, confocal laser endomicroscopy, optical coherence tomography, endo functional luminal imaging probes, wireless motility/pH capsule, wireless colon capsule endoscopy, endoscopic ultrasound, and discusses the basic principles of each technology, including adult indications and pediatric applications, safety cost, and training data.

  View details for DOI 10.1097/PG9.0000000000000224

  View details for PubMedID 37168622

• Cholangioscopy in Children & Adolescents: Utilization, Outcomes & Safety. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Berquist, W. E., Gugig, R. 2022

  Abstract

  BACKGROUND: Endoscopic Retrograde Cholangiopancreatoscopy (ERCP) is increasingly utilized for management of biliary disorders in children and adolescents. Practice patterns surrounding cholangioscopy in pediatric patients, however, are largely uncharacterized.METHODS: We retrospectively analyzed all ERCPs in which cholangioscopy was performed on patients 18 and under at our tertiary care children's hospital from 2015-2020 using our institution's paper and electronic medical record system. Patient demographics, procedure indications, interventions and associated adverse events were analyzed.RESULTS: Over the study period, 307 ERCPs were performed on 282 patients at our children's hospital. Cholangioscopy was performed in 36 procedures (11.7%) using the SpyGlass cholangioscope (Boston Scientific). Antibiotics to cover biliary organisms were administered to all patients pre-cholangioscopy. Mean patient age was 13.6 years (range 7 years - 18 years). The two most common indications for cholangioscopy included electrohydraulic lithotripsy for biliary stone disease and evaluation of biliary stricture (with incidental finding of biliary web in two patients and retained suture material in two patients). Adverse events were less prevalent in patients who underwent cholangioscopy relative to those who underwent ERCP. 0/36, (0%) developed post-ERCP pancreatitis, one patient had self-limited melena (possible self-limited post-sphincterotomy bleeding). Patient care was enhanced by cholangioscopy in 30/36 (83.3%) of these patients.CONCLUSIONS: These data attest to the safety and clinical utility of cholangioscopy in children and adolescents. Cholangioscopy was performed in just over 11% of pediatric patients who underwent ERCP at our academic medical center-rates similar to those reported in adult patients. The radiation-sparing nature of cholangioscopy, coupled with these data supporting its safety, make it particularly appealing for use in children. Further multi-institution evaluation of the utility, safety and range of indications for cholangioscopy in other practice settings would be of great interest and help guide endoscopic care.

  View details for DOI 10.1097/MPG.0000000000003499

  View details for PubMedID 35653429

• Landscape of Pediatric Endoscopic Ultrasound in a United States Tertiary Care Medical Center. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Cagil, Y., Gugig, R. 2022

  Abstract

  Endoscopic ultrasound (EUS) is a commonly used radiation-sparing 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.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's T-test, Pearson chi-square and Fisher's exact tests.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. 229 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.The diagnostic and therapeutic role for EUS in adults has expanded dramatically, however the role of EUS in pediatrics is not well-defined. In this, the largest pediatric EUS study to date, our data support the safety and utility of diagnostic and therapeutic EUS in pediatrics.

  View details for DOI 10.1097/MPG.0000000000003403

  View details for PubMedID 35149652

• Predictors of Prolonged Fluoroscopy Exposure in Pediatric ERCP: Results from the Large PEDI Multicenter Cohort. Journal of pediatric gastroenterology and nutrition Liu, Q. Y., Ruan, W., Fishman, D. S., Barth, B. A., Tsai, C. M., Giefer, M., Kim, K. M., Martinez, M., Dall'oglio, L., De Angelis, P., Torroni, F., Faraci, S., Bitton, S., Wilsey, M., Khalaf, R. T., Werlin, S., Dua, K., Huang, C., Gugig, R., Mamula, P., Fox, V. L., Grover, A., Quiros, J. A., Zheng, Y., Troendle, D. M. 2021

  Abstract

  BACKGROUND AND AIMS: Ionizing radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) is an important quality issue especially in children. We aim to identify factors associated with extended fluoroscopy time (FT) in children undergoing ERCP.METHODS: ERCP on children ≤18 years from 15 centers were entered prospectively into a REDCap database from 5/2014 until 5/2018. Data were retrospectively evaluated for outcome and quality measures. A univariate and step-wise linear regression analysis was performed to identify factors associated with increased FT.RESULTS: 1073 ERCPs performed in 816 unique patients met inclusion criteria. Median age was 12.2 years (IQR 9.3-15.8). 767 (71%) patients had native papillae. The median FT was 120 seconds (IQR 60-240). Factors associated with increased FT included procedures performed on patients with chronic pancreatitis, ERCPs with ASGE difficulty grade ≥3, ERCPs performed by Pediatric Gastroenterologist (GI) with Adult GI supervision, and ERCPs performed at non-free standing children's hospitals. Hispanic ethnicity was the only factor associated with lower FT.CONCLUSION: Several factors were associated with prolonged FTs in pediatric ERCP that differed from adult studies. This underscores that adult quality indicators cannot always be translated to pediatric patients. This data can better identify children with higher risk for radiation exposure and improve quality outcomes during pediatric ERCP.An infographic is available for this article at:http://links.lww.com/MPG/C570.

  View details for DOI 10.1097/MPG.0000000000003347

  View details for PubMedID 34724445

• Applicability, efficacy, and safety of over-the-scope clips in children. Gastrointestinal endoscopy Sharma, S., Barakat, M., Urs, A., Campbell, D., Rao, P., Schluckebier, D., Gugig, R., Thomson, M. 2021

  Abstract

  Over-the-scope clips (OTSCs) are now becoming popular in endoscopy performed in adults for indications such as acute nonvariceal GI bleeding, anastomotic bleeding, and for closure of gastrocutaneous and postgastrostomy fistulae. Varied sizes of clip are available, but even the smallest, 8.5 to 9.8 mm in diameter with its loading device on the tip of the endoscope, increases device and endoscope intubation diameters up to 14.65 mm. This may present challenges in terms of the size of the patient in whom it might be used. OTSCs appear to be effective and safe in the hands of those who are trained appropriately in endoscopy on adult patients; however, the experience of OTSC application in children is not reported. Here we present results of a service evaluation of this technology at 2 regional/national referral pediatric endoscopy units in the United Kingdom and the United States.Two tertiary centers' databases were searched to identify cases in which OTSCs were used. Demographics, presentation, anthropometry, comorbidities, efficacy, adverse events, and postprocedure follow-up were recorded, with identification of resolution or recurrence.OTSC procedures were performed on 24 occasions in 20 patients (11 girls) between February 2018 and February 2021. Patients had a mean age of 12 years (range, 5-17) and a mean weight of 44.42 kg (range, 18.2-70.3). Indications were nonhealing PEG site fistulae (n = 7), acute nonvariceal upper GI bleeding (ANUGIB) from gastric ulcers (5), ANUGIB from duodenal ulcers (3), nonhealing bleeding anastomotic ulcer (3), esophageal mucocutaneous fistula (1), and gastric perforation (1). Technical success was achieved in all but 1 case (95%), and clinical success was achieved in 18 cases (90%).The OTSC device appears to be effective in children (minimum age 5 years and minimum weight 18 kg) in a limited number of situations including anastomotic ulcer, closure of leaking PEG site, gastric perforation, and bleeding peptic ulcers. The operator should be an experienced endotherapeutic endoscopist with specific OTSC training, and the type and size of the OTSC device should be carefully considered, along with any comorbidities of the patient that may preclude success and/or lead to potential adverse events such as esophageal perforation.

  View details for DOI 10.1016/j.gie.2021.10.011

  View details for PubMedID 34662583

• Nationwide evolution of Pediatric ERCP Indications, Utilization and Re-Admissions over Time. The Journal of pediatrics Barakat, M. T., Cholankeril, G., Gugig, R., Berquist, W. E. 2020

  Abstract

  OBJECTIVES: We conducted the present all-capture US population level study of pediatric Endoscopic retrograde cholangiopancreatography (ERCP) P to analyze outcome and utilization trends over time.STUDY DESIGN: Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric hospitalizations (age <20 years) where ERCP was performed and assessed ERCP-associated readmissions. ICD-9-CM codes were used to identify hospitalization diagnosis, co-morbidities and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P < 0.05) of 30-day readmission.RESULTS: 11,060 hospitalized pediatric patients underwent ERCP from 2005-2014. Most were female (n=8859, 81%), 14-20 years of age (n=9342, 84%), and White (n=4230, 45%). 85% of ERCPs were therapeutic and leading indications were biliary (n=5350, 48%) and pancreatitis (n=3218, 29%). 13% of patients were re-admitted post-ERCP. Odds for 30-day re-admission were highest for patients with a history of liver transplant, ages between 0-4 years, male sex, and obesity (P < .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than rural hospitals for prolonged length of stay associated with ERCP.CONCLUSIONS: These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights regarding trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics and patient comorbidities associated with pediatric post-ERCP outcomes including re-admission and length of stay.

  View details for DOI 10.1016/j.jpeds.2020.11.019

  View details for PubMedID 33197494

• Return to Native Drainage: Duodenal Biliary Fistula Formation Following Pediatric Hepatobiliary Surgery with Roux-en-Y Reconstruction. Digestive diseases and sciences Barakat, M. T., Josephs, S., Gugig, R. 2020

  View details for DOI 10.1007/s10620-020-06372-6

  View details for PubMedID 32533541

• ENDOSCOPIC ULTRASOUND-GUIDED COIL PLACEMENT IS AN EFFECTIVE, SAFE AND RADIATION-SPARING APPROACH FOR MANAGEMENT OF GASTRIC VARICEAL BLEEDING IN CHILDREN AND ADOLESCENTS Barakat, M., Gugig, R. MOSBY-ELSEVIER. 2020: AB53

  View details for Web of Science ID 000545678400100

• THE MAJORITY OF CHILDREN AND ADOLESCENTS WITH PANCREAS DIVISUM AND ACUTE RECURRENT PANCREATITIS EXPERIENCE CLINICAL IMPROVEMENT AFTER ERCP WITH MINOR PAPILLOTOMY Barakat, M., Husain, S. Z., Gugig, R. MOSBY-ELSEVIER. 2020: AB500

  View details for Web of Science ID 000545678401137

• The Roles of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography in the Evaluation and Treatment of Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. Journal of pediatric gastroenterology and nutrition Liu, Q. Y., Gugig, R., Troendle, D. M., Bitton, S., Patel, N., Vitale, D. S., Abu-El-Haija, M., Husain, S. Z., Morinville, V. D. 2020; 70 (5): 681-693

  Abstract

  Pediatric chronic pancreatitis is increasingly diagnosed. Endoscopic methods [endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)] are useful tools to diagnose and manage chronic pancreatitis. Pediatric knowledge and use of these modalities is limited and warrants dissemination.Literature review of publications relating to use of ERCP and EUS for diagnosis and/or management of chronic pancreatitis with special attention to studies involving 0--18 years old subjects was conducted with summaries generated. Recommendations were developed and voted upon by authors.Both EUS and ERCP can be used even in small children to assist in diagnosis of chronic pancreatitis in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15 kg for EUS and 10 kg for ERCP can be technically challenging. These procedures should be done optimally by appropriately trained endoscopists and adult gastroenterology providers with appropriate experience treating children. EUS and ERCP-related risks both include perforation, bleeding and pancreatitis. EUS is the preferred diagnostic modality over ERCP because of lower complication rates overall. Both modalities can be used for management of chronic pancreatitis -related fluid collections. ERCP has successfully been used to manage pancreatic duct stones.EUS and ERCP can be safely used to diagnose chronic pancreatitis in pediatric patients and assist in management of chronic pancreatitis-related complications. Procedure-related risks are similar to those seen in adults, with EUS having a safer risk profile overall. The recent increase in pediatric-trained specialists will improve access of these modalities for children.

  View details for DOI 10.1097/MPG.0000000000002664

  View details for PubMedID 32332479

• The Roles of EUS and ERCP in the Evaluation and Treatment of Chronic Pancreatitis in Children: A Position Paper from the NASPGHAN Pancreas Committee. Journal of pediatric gastroenterology and nutrition Liu, Q. Y., Gugig, R., Troendle, D. M., Bitton, S., Patel, N., Vitale, D. S., Abu-El-Haija, M., Husain, S. Z., Morinville, V. D. 2020

  Abstract

  INTRODUCTION: Pediatric chronic pancreatitis (CP) is increasingly diagnosed. Endoscopic methods (endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)) are useful tools to diagnose and manage CP. Pediatric knowledge and use of these modalities is limited and warrants dissemination.METHODS: Literature review of publications relating to use of ERCP and EUS for diagnosis and/or management of CP with special attention to studies involving 0-18 years old subjects was conducted with summaries generated. Recommendations were developed and voted upon by authors.RESULTS: Both EUS and ERCP can be used even in small children to assist in diagnosis of CP in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15 kg for EUS and 10 kg for ERCP can be technically challenging. These procedures should be done optimally by appropriately trained endoscopists and adult gastroenterology providers with appropriate experience treating children. EUS and ERCP-related risks both include perforation, bleeding and pancreatitis. EUS is the preferred diagnostic modality over ERCP due to lower complication rates overall. Both modalities can be used for management of CP-related fluid collections. ERCP has successfully been used to manage pancreatic duct stones.CONCLUSIONS: EUS and ERCP can be safely used to diagnose CP in pediatric patients and assist in management of CP-related complications. Procedure-related risks are similar to those seen in adults, with EUS having a safer risk profile overall. The recent increase in pediatric-trained specialists will improve access of these modalities for children.

  View details for DOI 10.1097/MPG.0000000000002664

  View details for PubMedID 32079975

• Initial Experience with EUS-guided Coil Placement for Pediatric Gastric Variceal Hemostasis. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Foley, M. A., Gugig, R. n. 2020; Publish Ahead of Print

  Abstract

  Gastric variceal (GV) bleeding is among the most morbid sequelae of portal hypertension, with mortality ranging from 30-50%. Pediatric data focused on endoscopic approaches to management are needed. The present study represents the first pediatric case series of endoscopic ultrasound (EUS)-guided coil placement within feeding vessels as monotherapy for management of GV bleeding.Using our prospectively-maintained endoscopy database, we identified patients 18 years and younger who underwent EUS-guided coil placement for management of GV bleeding from 2008-2018. Demographics, indication, procedural interventions/findings, and available clinical outcomes data were analyzed.12 patients (median age 15, range 11-18 years) underwent EUS-guided coil placement for GV bleeding. All had portal hypertension, with EV in 58.3% and prior GV bleeding with attempted endoscopic management in 75%. Coil placement was accomplished using a linear echoendoscope and a 19-gauge needle. A mean of 2.75 (± 0.43) coils were placed in each patient (4, 6, 8, and 10 mm Nester Embolization Coils, Cook Medical). Immediate hemostasis was achieved in all patients, and 25% of patients developed recurrent gastric varices at a median of 5.5 months following the initial EUS-guided coil placement (range 4-6 months) over the median 12 month follow-up period.The present study establishes the feasibility and efficacy of EUS-guided coil placement as monotherapy for GV bleeding in children and adolescents. The technique was technically successful, with primary hemostasis achieved in all patients. EUS-guided embolization with coils may represent an alternative to current approaches for management of highly morbid GV bleeding.

  View details for DOI 10.1097/MPG.0000000000003028

  View details for PubMedID 33394889

• Fluoroscopy Time during ERCP performed for Children and Adolescents is Significantly Higher with Low-volume Endoscopists. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Gugig, R. n., Imperial, J. n., Berquist, W. E. 2020

  Abstract

  Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults, however the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP.We retrospectively analyzed ERCPs performed on patients < 18 years of age at our tertiary care children's hospital from 2002-2017 using our institution's paper and electronic medical record system along with a prospectively-maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume > 100 and low volume endoscopists (LVE) as < 100 (pediatric + adult) ERCPs/year.385 ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas) and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times varied dramatically between procedures and providers. Median fluoroscopy time was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of fluoroscopy time (p < 0.001). In addition to endoscopist volume, procedure-specific predictors of increased fluoroscopy time included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age < 4 years or > 16 years at the time of ERCP (p < 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with fluoroscopy time.Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower fluoroscopy time relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted fluoroscopy time for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.

  View details for DOI 10.1097/MPG.0000000000002914

  View details for PubMedID 32833892

• Out-of-pocket Cost Burden in Pediatric Inflammatory Bowel Disease: A Cross-sectional Cohort Analysis INFLAMMATORY BOWEL DISEASES Sin, A. T., Damman, J. L., Ziring, D. A., Gleghorn, E. E., Garcia-Careaga, M. G., Gugig, R. R., Hunter, A. K., Burgis, J. C., Bass, D. M., Park, K. T. 2015; 21 (6): 1368-1377

  Abstract

  Pediatric inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), can result in significant morbidity requiring frequent health care utilization. Although it is known that the overall financial impact of pediatric IBD is significant, the direct out-of-pocket (OOP) cost burden on the parents of children with IBD has not been explored. We hypothesized that affected children with a more relapsing disease course and families in lower income strata, ineligible for need-based assistance programs, disparately absorb ongoing financial stress.We completed a cross-sectional analysis among parents of children with IBD residing in California using an online HIPAA-secure Qualtrics survey. Multicenter recruitment occurred between December 4, 2013 and September 18, 2014 at the point-of-care from site investigators, informational flyers distributed at regional CCFA conferences, and social media campaigns equally targeting Northern, Central, and Southern California. IBD-, patient-, and family-specific information were collected from the parents of pediatric patients with IBD patients younger than 18 years of age at time of study, carry a confirmed diagnosis of CD or UC, reside in and receive pediatric gastroenterology care in California, and do not have other chronic diseases requiring ongoing medical care.We collected 150 unique surveys from parents of children with IBD (67 CD; 83 UC). The median patient age was 14 years for both CD and UC, with an overall 3.7 years (SD 2.8 yr) difference between survey completion and time of IBD diagnosis. Annually, 63.6%, 28.6%, and 5.3% of families had an OOP cost burden >$500, >$1000, and >5000, respectively. Approximately one-third (36.0%) of patients had emergency department (ED) visits over the past year, with 59.2% of these patients spending >$500 on emergency department copays, including 11.1% who spent >$5000. Although 43.3% contributed <$500 on procedure and test costs, 20.0% spent >$2000 in the past year. Families with household income between $50,000 and $100,000 had a statistically significant probability (80.6%) of higher annual OOP costs than families with lower income <$50,000 (20.0%; P < 0.0001) or higher income >$100,000 (64.6%; P < 0.05). Multivariate analysis revealed that clinical variables associated with uncontrolled IBD states correlated to higher OOP cost burden. Annual OOP costs were more likely to be >$500 among patients who had increased spending on procedures and tests (odds ratio [OR], 5.63; 95% confidence interval [CI], 2.73-11.63), prednisone course required over the past year (OR, 3.19; 95% CI, 1.02-9.92), at least 1 emergency department visit for IBD symptoms (OR, 2.84; 95% CI, 1.33-6.06), at least 4 or more outpatient primary medical doctor visits for IBD symptoms (OR, 2.82; 95% CI, 1.40-5.68), and history of 4 or more lifetime hospitalizations for acute IBD care (OR, 2.60; 95% CI, 1.13-5.96).Previously undocumented, a high proportion of pediatric IBD families incur substantial OOP cost burden. Patients who are frequently in relapsing and uncontrolled IBD states require more acute care services and sustain higher OOP cost burden. Lower middle income parents of children with IBD ineligible for need-based assistance may be particularly at risk for financial stress from OOP costs related to ongoing medical care.

  View details for DOI 10.1097/MIB.0000000000000374

  View details for Web of Science ID 000355315800020

  View details for PubMedID 25839776