Society: ASGE

Introduction: Transnasal endoscopy (TNE) is a valuable tool for endoscopic evaluation of the upper gastrointestinal tract while entirely avoiding the risk of general anesthesia in children. In the pediatric age group, often bronchoscopes are used for performing TNEs, which precludes the evaluation of the stomach and duodenum due to shorter length and overall suboptimal visualization. In this study, we evaluated a novel ultrathin gastroscope (EvoEndo®) in children and adults.

Methods:
This is a multicenter retrospective study between May and November 2022. There were a total of 6 participating sites across the USA. Data was collected from the electronic medical record. Primary outcome was the safety and efficacy of EvoEndo® single use transnasal gastroscope by measuring the success rate, adverse events and overall tolerability. Secondary outcomes included duration of procedure and encounter, and biopsy adequacy.

Results: Thirty six patients were recruited during the study period. Indications included dysphagia, eosinophilic esophagitis and esophageal varices surveillance. Mean age was 16.1 years ± 6.1 (6-37 years) with a male predominance (86.1%). 35/36 subjects underwent TNE for varying clinical indications and targeted anatomy. One procedure was aborted prior to initiation. 3 subjects underwent transnasal esophagoscopy (TN-Eso), 26 transnasal gastroscopy (TN-EG), and 3 transnasal esophagogastroduodenoscopy (TN-EGD). The procedure was successful in 91.4%. 3 procedures were unable to be completed. Two due to reported patient anxiety and swollen turbinates and 1 the upper esophageal sphincter was unable to be intubated. 50% underwent TNE for the first time. Biopsies were performed in all completed procedures except the 2 patients undergoing esophageal varices surveillance, and were adequate for histopathological analysis. Median procedure duration was 11 minutes (IQR: 7-16 minutes) and median visit duration was 33.5 minutes (IQR: 30-39 minutes). Half of the procedures were performed in the outpatient clinic setting while the other half were performed in an endoscopy suite. No significant adverse events occurred.

Conclusion: Ultrathin TNE using the EvoEndo® single use gastroscope was well tolerated and safe in the pediatric and adult age groups with a success rate similar to previously reported studies. User feedback noted EvoEndo’s single use gastroscopes provided improved visualization, further reach into the upper gastrointestinal tract, and a larger working channel allowing for diagnostic EGD in an efficient ambulatory setting without the need for general anesthesia.

Background: Endoscopic ultrasound (EUS) is increasingly used in adults for various diagnostic and therapeutic purposes. In the pediatric population, the use of EUS has been historically diagnostic, however, its use continues to evolve with an increasing trend toward minimally invasive EUS-guided therapy. In this retrospective study, we aim to describe the safety and efficacy profiles of EUS in pediatric patients across a spectrum of EUS procedures.
Methods: This is a retrospective multi-center cohort study of pediatric patients who underwent EUS procedures for diagnostic or therapeutic purposes between January 2011 and September 2022 at two US tertiary centers. Data including demographics, procedural details, and adverse events (AE) were collected. Outcomes were diagnostic success, defined as successful diagnosis using only EUS without any additional diagnostic tests, and therapeutic success, defined as using only EUS without additional therapeutic interventions.
Results: 68 pediatric patients, of which 39 were females (57.4%), between the age of 0 to 18 years, underwent 83 EUS procedures, The mean age was 16.1 ± 4.1 years, and the median weight was 67.5 kg (IQR 50.5-88.4). Indications for EUS were gastrointestinal lumen evaluation ± fine needle biopsy/aspiration (FNB/A), pancreaticobiliary tree evaluation ±FNB/A, surveillance for neoplastic syndrome, suspected lymph node (LN) or gastrointestinal (GI) mass, celiac plexus block, cystgastrostomy and gastrojejunostomy creation (Table 1). The median procedure time was 35 minutes (IQR 18.5 – 50.5). The diagnostic success rate was 98.0%, and therapeutic success rate was 100%. The EUS-related complication rate was 2.4% which included 2 cases of pancreatitis after fine needle aspiration of the pancreas. 2 cases had anesthesia-related complications.
Conclusion: In this multi-center retrospective cohort study, using EUS in pediatrics is safe and effective across various diagnostic and therapeutic intents.

Table 1 - Demographic, procedural details and outcomes of 68 pediatric patients who underwent 83 EUS procedures

Table 1 - Demographic, procedural details and outcomes of 68 pediatric patients who underwent 83 EUS procedures

Background: Surgical treatment of severe tracheomalacia that entails a Posterior Tracheopexy (PT) requires significant lateral esophageal mobilization to provide space for the posterior wall of the trachea to be sutured to the anterior border of the spine. We have observed that such esophageal mobilization can lead to new-onset postoperative dysphagia secondary to an abrupt esophageal angulation that functionally and anatomically behaves like an esophageal stricture. We sought to describe the characteristics, frequency, risk factors and management of such new entity that we have termed Posterior Tracheopexy Related Esophageal Stricture (PTRES).
Methods: A single-center, retrospective, case-control study at a tertiary pediatric hospital was performed. Records of all patients who underwent PT between 2016 to 2020 were reviewed. Cases of symptomatic PTRES requiring endoscopic balloon dilation were compared to a random sample of control patients who underwent PT without PTRES (1 case:3 controls sampling strategy). Modified Functional Oral Intake Scores (mFOIS) were determined from chart review. Univariate and multivariate analysis of patient and procedural characteristics was performed to identify risk factors for PTRES.
Results: Out of 396 patients who underwent PT during the study period, 27 (6.8%) developed PTRES requiring dilation. A total of 60 dilations with median 2 (IQR: 1,3) per patient were performed to treat PTRES, starting at median of 28 (IQR: 17,37) days postoperatively. All PTRES had appearance of extrinsic stricture frequently with associated abrupt esophageal angulation. Of 24 cases with recorded location of PTRES, 22 (91.6%) were in either proximal or upper third of esophagus, corresponding to thoracic inlet. There were no perforations or complications from dilation. No patients required a reoperation. Compared to control group (n=81) there was no difference in gender, age <1 year, direction of esophageal mobilization, highest pexy suture, number of rows of pexy sutures, cervical incision, eosinophilic esophagitis, or congenital esophageal stricture (table 1). On univariate analysis, absence of esophageal atresia (EA), greater weight, history of great vessel anomaly, vascular ring and greater preoperative mFOIS were significantly associated with PTRES (table 1). Multivariable analysis identified EA (OR 0.26), history of vascular anomaly without ring (OR 3.84) and greater preoperative mFOIS (OR 1.74) as significant factors for development of PTRES (table 2).
Conclusion: Although rare, esophageal stricture can occur following posterior tracheopexy. Symptoms usually appear within 6 weeks of surgery. Dysphagia typically improves with 1-2 endoscopic dilations which appear well tolerated. Absence of esophageal atresia, history of vascular anomaly without ring and greater baseline swallowing function are risk factors for stricture development.

Introduction: Achalasia is rare in children with incidence of ~0.1 per 100,000 (compared to ~2/100,000 in adults). Historically, achalasia in children has been treated with laparoscopic Heller myotomy (LHM) or pneumatic dilatation (PD). PD has poor durability and significant perforation risk and recent systematic reviews suggest modest LHM efficacy in children (e.g. 78% LHM vs 99% POEM in Goneidy, Eur J Pediatr Surg. 2020). Pediatric POEM studies in the literature have limitations that include low sample size, short follow-up and retrospective methodology (Nabi, Dysphagia 2022). To address this gap in the literature we proceeded to analyze our pediatric POEMs leveraging our experience as the first center to perform POEM in the US (Stavropoulos, GIE 2010) with the highest reported POEM volume (Modayil, GIE 2021) and comprehensive, detailed, long-term, prospective follow-up. Methods: From our prospectively-maintained database of 787 consecutive POEMs (10/2019-11/2021) we abstracted all POEMs performed in patients ≤18 years old. 30 POEMs were identified (4%). The first was in 2013, 4 years after our first POEM (POEM #53 in our series), as we waited until after our initial learning phase to extend POEM to pediatric patients. We analyzed patient/procedural characteristics and outcomes including efficacy, adverse events (AEs), length of stay, and detailed objective GERD assessments. Results (see Tables): Mean age was 14.7 (7-18), 60% male with BMI of 21 and mean weight-loss of 14 lbs (0-65). 90% type I/II, 3.5% type III and 3.5% EGJOO. Mean disease duration was 33 months (4-132).43% had prior treatments. Remarkably 9(30%) had prior myotomy (8 LHM, 1 POEM). 20 (66%) had syndromes/conditions including hereditary and/or congenital conditions potentially associated with achalasia (table). Our technique has been stable over the years with full-thickness myotomy, hybrid knife, Overstitch closure in >90% of patients. Median POEM time 38 min. At median follow-up 3.4 years [1.8-7.1] 100% technical and clinical success despite difficult salvage POEMs in pts with prior myotomy. Only 1 pt (3%) missing follow-up (declined f/up after 4^th year post-POEM). Two prolonged stays for observation without any severe AEs (requiring intervention, transfusion, ICU, re-admission or resulting in disability). We were able to obtain objective GERD assessment in 83% of patients at median of 6 months post-POEM. Esophagitis in 37%, + pH study in 35% (but favorable mean acid exposure/DeMeester scores of 5.7%, 25.6). Only 1 GERD sequela (stricture) in pt with gastroparesis and paraesophareal hernia. Conclusion: We present possibly the largest US series of pediatric POEM with long term follow-up and comprehensive objective GERD assessment. POEM is a safe and effective minimally invasive alternative to LHM in children as primary therapy and rescue therapy after prior LHM or PD

Baseline Characterstics and Technique

Outcomes: Efficacy, GERD and Adverse Events

Outcomes: Efficacy, GERD and Adverse Events

Objective: Develop a semi-automated EMR based quality improvement system for monitoring delayed procedural complications (PC) in pediatric endoscopy tertiary care center for the division of Gastroenterology, Hepatology and Nutrition at Children’s Wisconsin (CW)
Design: Three automated reports were created to track PC within 30 days of an endoscopic procedure.
Setting: Single center study performed at an academic, tertiary referral center over a 36-month period, from January 2017 to December 2019.
Patients and interventions: Quality Improvement reports were created using the Epic Clarity data base and SQL Server Reporting Services. Total of 9596 endoscopic procedures were performed during the study period, cases identified as having a PC were further analyzed.
Main outcome measurements: Procedure type, ED visit, return to the operating room, unplanned stays post-procedure and prolonged stays post procedure. Events were graded using recently described classification system for post-endoscopy events. Grade 1 - no intervention; Grade 2 - ED evaluation; Grade 3 - hospitalization and/or significant intervention; Grade 4 - unplanned surgery, or ICU admission; and grade 5 - death.
Results: A total of 193 complications (2%) were identified in all three categories. Seventy cases (0.7%) were noted to be a direct result of an endoscopic procedure. Higher rates of complications were observed after therapeutic cases versus diagnostic ones (2.6 % vs 0.3%, p=<0.00001). Analysis did not reveal any significant differences between years overall or within diagnostic, therapeutic and gastrostomy tube categories. A total of 36 (0.5%) anesthesia related complications were identified with respiratory distress being the most common (66%, n=24). The majority (83%, n=30) of patients who experienced anesthesia complications had an ASA classification of 3 or higher.
Limitations: Single center study
Conclusions: Diagnostic endoscopy remains a very safe procedure and risk of both endoscopy and sedation related complications are low. Therapeutic procedures carry a higher risk but still overwhelmingly safe. Development of a systematic quality improvement program around endoscopy is paramount to continue to improve the safety of pediatric endoscopy and investment in such programs can make them more automated and sustainable. To our knowlege this is the first semi-automated EMR based PC system described for monitoring delayed complications in pediatric endoscopy.

Procedure Volume and Complications Data over 3 years

Procedure Volume and Complications Data over 3 years

Complication Report including return to ED, Return to OR or Prolonged Stay

Complication Report including return to ED, Return to OR or Prolonged Stay

Diana Lerner

Medical College of Wisconsin

Appearances