key: cord-0825073-tkf2l5kq
authors: Ruan, Wenly; Fishman, Douglas S.; Lerner, Diana G.; Furlano, Raoul I.; Thomson, Mike; Walsh, Catharine M.
title: ID: 3526575 EVOLUTION OF INTERNATIONAL PEDIATRIC ENDOSCOPIC PRACTICE CHANGES DURING THE COVID-19 PANDEMIC
date: 2021-06-30
journal: Gastrointestinal Endoscopy
DOI: 10.1016/j.gie.2021.03.770
sha: 4ae9d4a70c965140921617afcbb9e4d821eeda92
doc_id: 825073
cord_uid: tkf2l5kq

nan

Introduction: Pediatric patients with suspected choledocholithiasis may undergo serial imaging and labs to determine the next steps in management. Trans-abdominal ultrasound (TUS) is commonly used but has poor sensitivity for identifying common bile duct stones (CBD) and there is lack data on the changes in the bile duct diameter in this population. This is the first study to evaluate the predictive value of serial CBD measurements and laboratory values in planning for endoscopic retrograde cholangiopancreatography (ERCP) and/or cholecystectomy. Methods: A retrospective review of pediatric patients (0-18 yrs) presenting with suspected choledocholithiasis between 1/2016 and 6/2020 was conducted. Charts were reviewed for demographics, laboratory values and imaging data, and clinical outcomes. Patients were grouped by whether they underwent ERCP, and whether CBD stone was found at time of ERCP, and compared using Chi square test (Table 1) . Changes in mean CBD size and laboratory values were compared between groups using independent T-test. Results: 162 patients (7 months -18 years) presented with suspected choledocholithiasis. 5 patients status post cholecystectomy were excluded from analysis. Two patients who underwent endoscopic ultrasound and intraoperative cholangiogram, respectively, were included. Of the remaining 157 patients, 95 (60.5%) underwent ERCP, of which 71 (74.7%) had a CBD stone at time of ERCP. Patients with suspected choledocholithiasis without ERCP (No ERCP Group) had higher rates of pancreatitis on admission (p Z 0.004), MRCP (p Z 0.001), were more likely to have been transferred from an outside facility (p Z 0.015), and were less likely to have a CBD stone visualized on imaging (p < 0.001) ( Table 1 ). Patients without ERCP had larger decreases in CBD size (p Z 0.041) on serial TUS and GGT on serial labs (p Z 0.015) ( Table 2) . Patients with a CBD stone at time of ERCP were less likely to have sludge at time of ERCP (p Z 0.008), and less likely to have an adverse event associated with ERCP or anesthesia (p Z 0.002). Patients with stone at time of ERCP had higher mean conjugated bilirubin levels the day of ERCP, and smaller changes in GGT on serial labs (p Z 0.013) ( Table 2) . Conclusion: Patients who underwent ERCP had overall smaller variation of change in CBD size on serial TUS compared to those who did not undergo ERCP. The "No ERCP" and "No CBD Stone at ERCP" Groups had larger decreases in GGT, suggesting a favorable role in identifying patients with choledocholithiasis who require ERCP. These preliminary data suggest the magnitude of the decrease in CBD on serial TUS may be beneficial in eliciting which patients could forego ERCP and related procedures. More research is planned to evaluate whether monitoring changes in CBD size will the predictive value of CBD stone at time of ERCP. Background: The coronavirus disease 2019 (COVID-19) pandemic has drastically altered endoscopic practice. In April 2020, we evaluated the initial impact of the COVID-19 pandemic on pediatric endoscopic practice globally. This follow-up study aims to assess changes in endoscopic practices 7 months following the initial survey to delineate the patterns of practice change as the pandemic evolves. Methods: Pediatric gastroenterologists who responded to the initial survey (April 2020) were re-surveyed in November 2020 using REDCap. The survey recorded information on changes in pediatric endoscopic practice patterns, including COVID-19 screening processes and personal protective equipment (PPE) utilization. Results: Surveys representing 75 unique institutions worldwide were completed out of the 145 initial responses (51.7% response rate). Current characteristics of these institutions related to COVID-19 are detailed in Table 1 . Overall, procedural volumes increased at most institutions (nZ53, 70.7%). Previously, 80% of institutions were postponing all elective cases, whereas now, the majority are no longer postponing elective (nZ57, 76%) and emergent/urgent procedures (nZ72, 96%). Most have started to perform previously postponed cases (nZ69, 90.7%). Thirty-one institutions (41.3%) report changes to pre-endoscopy screening questionnaires, with inclusion of more symptoms. 89.3% of institutions (nZ67) have a protocol in place to address patients who screen positive compared to 78% (nZ110) previously. Thirty-one institutions (41.3%) also report changes to pre-endoscopy SARS-CoV-2 testing, with most being performed to triage patients (nZ56, 74.7%), determine a PPE strategy for positive patients (nZ31, 41.3%), and/or determine anesthesia risk (nZ20, 26.7%). Twentysix institutions (34.7%) have performed procedures on COVID-19 positive patients. If patients test positive, most institutions (nZ66 for upper endoscopies, 88.0%; nZ64 for lower endoscopies, 85.3%) proceed with urgent/emergent procedures, while most institutions (nZ47 for upper endoscopies, 62.7%; nZ45 for lower endoscopies, 60%) postpone elective procedures for a specific timeframe. Twenty-two institutions (29.3%) have changed their PPE recommendations since April 2020. Most respondents' personal PPE practices did not differ from their institutional guidelines (nZ65, 86.7%). Given the initial concerns over PPE shortages, 38.5% of hospitals had reported reusing surgical masks and 67.8% were reusing N95/N99 masks. Currently, 26.7% of hospitals are reusing surgical masks and 54.7% are reusing N95/99 masks, with mask renewal based on the number of days of endoscopy. Conclusions: This is the first survey to highlight the evolution of pediatric endoscopic practice related to the evolving COVID-19 pandemic, highlighting the need for ongoing pandemic-related guidance for pediatric endoscopic practice. Background: Liver biopsy performed after less invasive workup for evaluation of abnormal liver function studies occasionally reveals large bile duct obstruction on histology. Our data from the adult population indicate that over 80% of patients with histologic evidence of large duct obstruction who undergo endoscopic retrograde cholangiopancreatography (ERCP) have biliary findings amenable to endoscopic therapy. The utility of ERCP in this setting has not been studied in pediatrics. In the present study, we address this important clinical issue. Methods: A retrospective review of our pediatric pathology and clinical records from 2010-2019 identified 123 pediatric patients with large duct obstruction on liver biopsy. The absolute standardized difference (ASD) was used to compare baseline covariates between patients who underwent ERCP vs. all others. Covariates included age, gender, race, ethnicity, BMI, and labs (total bilirubin, GGT, alkaline phosphatase, AST, ALT, platelets, and INR). The higher the ASD, the larger the difference between the two groups. A value less than 0.2 denotes a small effect size. Results: There were 85 unique patients who met our inclusion/ exclusion criteria (Figure 1 , Additional multi-center studies including more patients and focused on understanding the utility of ERCP and range of outcomes following the diagnosis of large duct obstruction in pediatrics would be informative to guide pediatric hepatology and endoscopic practices.

Pediatric Endoscopy Lecture ID: 3524415 GASTROINTESTINAL BLEEDING IN PEDIATRIC PATIENTS WITH VENTRICULAR ASSIST DEVICES: RATES, ENDOSCOPIC INTERVENTIONS & CLINICAL IMPACT

Background: Ventricular assist devices (VAD) are increasingly utilized for cardiovascular support of critically ill children and adolescents. Hemostatic complications are common in patients with VAD due to converging pathophysiologic mechanisms leading to dysregulated hemostasis. When bleeding occurs in a VAD patient, identification of the source and severity of bleeding to achieve expeditious source control, implementation of adequate resuscitation to stabilize hemodynamics and decisions regarding anti-coagulation management are key considerations. Limited adult studies