Endoscopic retrograde cholangiopancreatography (ERCP) is increasing as a pediatric gastrointestinal diagnostic and therapeutic modality. However, ERCP is associated with ionizing radiation exposure, and in adult gastroenterology literature, radiation exposure is reduced if procedures are performed by high-volume endoscopists. It is unknown if this same finding occurs with pediatric gastroenterologists who perform ERCP.
The authors of this study performed a retrospective review of all pediatric ERCPs completed at a single, large children’s hospital over a 15-year period (2002-2017). ERCPs in this setting were performed by both adult and pediatric gastroenterologists, and a “highvolume gastroenterologist” was defined as one who performed greater than 100 adult and pediatric ERCPs per year while a “low-volume gastroenterologist” was defined as one who performed less than 100 such procedures. Each gastroenterologist had ERCP data reviewed including obtaining information about each pediatric patient (age, sex, diagnosis, and ERCP intervention). Fluoroscopy time during ERCP was compared between high-volume and low-volume gastroenterologists.
A total of 385 ERCPs were performed on 321 patients by 8 gastroenterologists (5 adult; 3 pediatric). Three adult gastroenterologists and one pediatric gastroenterologist were high-volume providers while the rest were low volume. A separation into high- versus low-volume providers demonstrated that 175 ERCPs were performed by low-volume gastroenterologists and 210 were performed by high-volume gastroenterologists. The average patient age was 13.4 years with 51% of patients being Caucasian. All patient variables did not differ significantly between low-volume and high-volume gastroenterologists. Throughout the study, the proportion of therapeutic ERCPs increased significantly over time. Median fluoroscopy time per procedure was 4.85 (± 2.68) minutes. High-volume gastroenterologists had a median fluoroscopy time of 2.04 minutes which was significantly lower than low-volume gastroenterologists who had a median fluoroscopy time of 5.21 minutes. Univariate and multi-variate analyses also demonstrated significantly increased fluoroscopy time for patients who needed an ERCP for a pancreas disorder, for patients with any type of ductal stricture, and for any patient less than 4 years of age or greater than 16 years of age. Significantly decreased fluoroscopy time was associated with patients who had undergone prior ERCP. The ASGE Procedure Complexity Scale for patient procedures did not predict fluoroscopy time although the Stanford Fluoroscopy Complexity Scale did show a significant correlation between total fluoroscopy time and increasingly complex pediatric procedures. Finally, ERCPs with fluoroscopy controlled by a radiology technician or radiologist had significantly higher fluoroscopy time compared to endoscopist-controlled fluoroscopy, and C-arm use was associated with significantly more fluoroscopy time compared to use of a fixed fluoroscopy unit.
This study demonstrates that high-volume endoscopists who perform ERCP utilize less fluoroscopy time comparted to low-volume endoscopists. Also, the person controlling the fluoroscopy and type of machine providing imaging appears to effect exposure time. Multicenter as well as prospective studies are needed to confirm these important findings This study demonstrates that high-volume endoscopists who perform ERCP utilize less fluoroscopy time comparted to low-volume endoscopists. Also, the person controlling the fluoroscopy and type of machine providing imaging appears to effect exposure time. Multicenter as well as prospective studies are needed to confirm these important findings