低年资内镜医师行儿童和青少年内镜逆行胰胆管造影术时透视时间显著更长。
Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Performed for Children and Adolescents is Significantly Higher With Low-volume Endoscopists.
机构信息
Division of Gastroenterology and Hepatology, Stanford University School of Medicine.
Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA.
出版信息
J Pediatr Gastroenterol Nutr. 2021 Feb 1;72(2):244-249. doi: 10.1097/MPG.0000000000002914.
BACKGROUND
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.
METHODS
We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002 to 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.
RESULTS
Three hundred eighty-five 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 (FTs) varied between procedures and providers. Median FT was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P < 0.001). In addition to endoscopist volume, procedure-specific predictors of increased FT 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 FT.
CONCLUSIONS
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 FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT 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.
背景
内镜逆行胰胆管造影术（ERCP）是一种基于荧光透视和内镜的程序，对于儿科胰胆疾病的诊断和治疗非常重要。患者、手术、内镜医师和医疗机构的特征已被证明会影响 ERCP 的复杂性和手术结果以及成人的荧光透视利用率；然而，在儿科患者中，这种情况的程度仍在研究中，关于儿科 ERCP 中荧光透视利用率的数据很少。
方法
我们使用机构的纸质和电子病历系统以及前瞻性维护的辐射暴露数据库，对 2002 年至 2017 年在我们的三级儿童医院进行的年龄小于 18 岁的患者的 ERCP 进行了回顾性分析。使用斯坦福荧光透视复杂性评分和美国胃肠内镜协会复杂性评分来评估手术的复杂性。高容量内镜医师（HVE）定义为每年有 100 次以上的累积 ERCP 量，低容量内镜医师（LVE）定义为每年 <100 次（儿科+成人）ERCP。
结果
本分析共纳入 321 例患者的 385 例 ERCP。患者平均年龄为 13.4 岁（+/-4.2 岁），77%为首次 ERCP（原发性壶腹），81%为治疗性（87%为胆管指征，13%为胰腺指征）。荧光透视时间（FT）在不同的手术和提供者之间存在差异。中位数 FT 为 4.85（+/-2.68）分钟。内镜医师每年的 ERCP 量是 FT 的最强预测因素（P < 0.001）。除了内镜医师的数量外，FT 增加的预测因素还包括手术的胰腺指征、胆管或胰腺管狭窄、ERCP 时患者年龄 <4 岁或 >16 岁（每项 P < 0.01）以及原发性壶腹。基于斯坦福荧光透视复杂性评分的 ERCP 复杂性评分与 FT 相关。
结论
儿科 ERCP 的辐射暴露量高于理想水平，且与内镜医师以及患者和手术特定因素有关。尽管 HVE 的手术复杂性较高，但与 LVE 相比，HVE 进行 ERCP 的 FT 较低。斯坦福荧光透视评分预测了儿科 ERCP 的 FT，但美国胃肠内镜协会的 ERCP 复杂性评分则没有。适应和完善儿科特定的 ERCP 复杂性评分，包括患者体型和年龄以及更符合儿科患者的指征/干预措施等因素，可能会有所帮助。
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