Table 1 Included study characteristics by population

Rescorla (1995) [40]

Retrospective

USA

6

NR

4.8y

Pancreatic:6

Biliary:0

other/unknown:0

100%

All six patients underwent distal

67%

Two children had increased abdominal pain for 12 to 18 hours after ERCP, and one had an elevated temperature (>38°C). There were no serious adverse effects related to ERCP

Zargar (2003) [57]

Retrospective

USA

16

6 boys 10 girls

12.6y

Pancreatic:0

Biliary:7

other/unknown:9

93.8%

The complete bile duct clearance was achieved in 15 patients—in the first attempt in nine patients and two attempts in six patients. In 11 patients, pus, brown muddy. One patient with gallbladder stones underwent cholecystectomy.

6%

One patient developed hemorrhage immediately after ES, which resolved without blood transfusion. There were no deaths.

Prasil (2001) [38]

Retrospective

Canada

20

8 boys 12girls

11.3y

Pancreatic:5

Biliary:15

other/unknown:0

90.5%

In 11 patients, the ERCP was diagnostic only, and in 10 a therapeutic procedure was done

33%

6 episodes of pancreatitis. 4 of which followed a therapeutic procedure, and 1 episode of bleeding

Green (2007) [23]

Retrospective

USA

19

6 boys

13 girls

13y

Pancreatic:4

Biliary:11

other/unknown:1

89.5%

In two cases, the intended therapeutic procedure was not completed.

One was the result of a CBD stone migrating and becoming lodged in the cystic duct. In the other, the bile duct could not be cannulated, presumably because a stone was impacted distally

0%

Tagge (1997) [45]

Retrospective

USA

26

11 boys

25 girls

10.1y

Pancreatic:5

Biliary:21

other/unknown:0

96%

The pancreaticobiliary tree was successfully visualized by ERCP in 25 of 26 patients.

4%

one death occurring in a trauma patient unrelated to his pancreaticobiliary disorder.

Paris (2010) [7]

Retrospective

Canada

29

21 girls 8 boys

10.3y

Pancreatic:29

Biliary:9

other/unknown:0

97%

Only one failure to cannulate the papilla in a patient with chronic pancreatitis was encountered.

13.5%

No severe pancreatitis, perforation, or bleeding was noted.

Rocca (2005) [41]

Retrospective

Italy

38

14 boys

24 girls

10y

Pancreatic:14

Biliary:24

other/unknown:0

97%

Successful cannulation of the major papilla with subsequent opacification of biliary tracts or pancreatic duct was

achieved in all the patients at the first attempt, except for those

with extra-hepatic biliary atresia (three cases) and for one

5-week-old infant with cholestasis (final diagnosis: choledochal sludge)

6%

two post-sphincterotomy bleedings (treated conservatively) and one mild pancreatitis

Teng (2000) [47]

Retrospective

Jepan

42

14 boys 28 girls

NA

Pancreatic:11

Biliary:31

other/unknown:0

100%

2%

Mild cholangitis occurred as a complication in 1 patient, but was alleviated with medication.

Halvorson (2013) [24]

Retrospective

USA

45

25 boys, 20 girls

12y

Pancreatic:22

Biliary:32

other/unknown:0

97.1 %

The aforementioned patient whose ERCP was aborted was a procedural failure, as well as another patient who underwent an ERCP for a pancreatic duct leak, but whose pancreatic duct disruption could not be traversed during the study

7%

Complications included infection (moderate-1), bleeding (moderate-1), and post-ERCP pancreatitis (mild-1, moderate-2)

Vegting (2009) [52]

Retrospective

Netherlands

61

38 boys 23 girls

7y

Pancreatic:10

Biliary:51

other/unknown:0

71%

This lower success rate was related to the relatively large group of young children with biliary atresia, in whom it is impossible to visualize the ductal system.

8%

One patient experienced pancreatitis after ERCP and was treated conservatively. After 3 ERCPs in 2 different patients, pancreatic irritation occurred (abdominal pain and slight elevation of amylase).

Other complications were directly related to the therapeutic interventions and included stent dislocation in 2 patients and stent occlusion in 3 patients

Issa (2007) [26]

Retrospective

Saudi Arabia

125

77 boys 48 girls

13.3y

Pancreatic:9

Biliary:115

other/unknown:0

96.8%

children while cannulation of the Ampulla failed in four.

4%

There was no mortality. One had bleeding from the site of sphincterotomy which stopped after adrenaline injection. Four patients (3.2%) developed transient

mild pancreatitis which settled conservatively.

Troendle (2013) [48]

Retrospective

USA

65

46 girls, 19 boys

15.2y

Pancreatic:15

Biliary:50

other/unknown:0

100%

5%

Adverse events included 3 episodes of mild pancreatitis, 1 episode of moderate bleeding, and 1 episode of sphincterotomy clot causing obstruction and need for repeat ERCP within 1 week.

Varadarajulu (2004) [51]

Retrospective

USA

116

NR

9.3y

Pancreatic:49

Biliary:60

other/unknown:7

97.5%

2%

Complications were of mild severity and occurred only in association with grade III procedures

Agarwal (2014) [12]

Retrospective

India

172

102 boys, 70 girls

13.8y

Pancreatic:172

Biliary:0

other/unknown:0

83%

2 had no improvement in pain, and 2 underwent a surgical drainage procedure. 12 patients had pain relief.

4%

Mild post-ERCP pancreatitis occurred in 2 patients (1.5%),

abdominal pain with normal serum amylase/lipase levels in 6 patients (3.4%) requiring admission (n = 3) or prolongation of hospital stay by 2 to 3 days (n =3)

Dua (2008) [18]

Retrospective

USA

185

112 girls 73 boys

NA

Pancreatic:43

Biliary:71

other/unknown:71

98%

In one patient, cannulation was unsuccessful and, in another, the endoscope could not be advanced into the duodenum because of altered gastric anatomy

2%

Complications noted were mild pancreatitis in two and self-limited bleeding in one

Otto (2011) [33]

Prospective

USA

167

98 girls 69 boys

14.4y

Pancreatic:148

Biliary:31

other/unknown:0

72%

ERCP was successful in identifying a source for recurrent pancreatitis, and nearly half of the patients with an identified anatomic abnormality went on to surgical intervention

5%

Complications occurred for only 11 patients (4.76%), including 7 cases of post-ERCP pancreatitis

Saito (2014) [43]

Retrospective

Japan

220

85 boys, 135 girls

4y

Pancreatic:5

Biliary:181

other/unknown:32

96%

10%

Hyperamylasemia developed in 9.4%

Limketkai (2013) [29]

Retrospective

USA

154

68 boys and 86

girls

11.5y

Pancreatic:52.2%

Biliary:47.8%

other/unknown:8

94.1 %

due to an inability to cannulate the duct of interest: biliary or pancreatic in some patients

6%

post-procedure pancreatitis (12 cases; 4.2 %), hypoxia (3; 1.0 %), and hemorrhage (2; 0.7 %)

Giefer and Kozarek (2015) [21]

Retrospective

USA

276

181 girls 95 boys

13.6y

Pancreatic:210

Biliary:194

other/unknown:11

95%

13%

The most common complication was post-ERCP pancreatitis which occurred in 26 cases (7.7 %)

Enestved (2013) [20]

Retrospective

USA

296

210girls, 219boys

14.9y

Pancreatic:51

Biliary:268

other/unknown:92

95.2%

3 were deemed to be the result of an endoscopist-related factor such as inability to identify an ampulla, bleeding from a precut sphincterotomy precluding cannulation, or inability to advance beyond the pylorus because of altered anatomy.

The remaining 3 cases in which cannulation was not attempted were associated with a non–endoscopist-related factor, including the inability to adequately anesthetize the patient and precipitation of a severe nasal hemorrhage during anesthesia induction

17%

Post-ERCP pancreatitis occurred in 6.3% (27) of ERCPs, which included 5 cases in which patients were admitted with acute pancreatitis and the ERCP resulted in an exacerbation of their pancreatitis

Abdominal pain (in the absence of fever or pancreatitis),

which prolonged hospital stay, occurred after 24 (5.6%) ERCP

patients.

Brown (1993) [14]

Retrospective

USA

92

60 girls 32 boys

4 months to 19 years

Pancreatic:35

Biliary:12

other/unknown:53

95.8%

The most common findings included chronic pancreatitis (26 cases), pancreas divisum (14), dilated pancreatic duct (10), gallstones or sludge (8), and abnormal common bile duct (8).

15.21%

4 cases of post-ERCP pancreatitis

Perrelli (1996) [35]

Retrospective

Italy

5

3 boys, 2 girls

10.8y

Pancreatic:5

Biliary:0

other/unknown:0

100%

Endoscopic pancreatic sphincterotomy, with or without removal of calculi, was performed in four cases (2 in the authors' hospital, 2 in another institution).

0%

No deaths or complications occurred.

Hsu (2000) [25]

Retrospective

USA

22

10.7y

Pancreatic:22

Biliary:0

other/unknown:0

100%

6%

Both patients had undergone sphincter manometry and developed mild pancreatitis. One patient had only a diagnostic manometry and the other had also undergone a biliary sphincterotomy.

Poddar (2017) [37]

Retrospective

India

72

34 girls 38 boys

8.8y

Pancreatic:28

Biliary:44

other/unknown:0

97%

Of the 44 cases with suspected biliary tract disease, 14 had a choledochal cyst, 13 had portal biliopathy, two each had CBD stones, primary sclerosing cholangitis and a bile leak, one had biliary ascariasis, eight had a normal cholangiogram, and CBD cannulation failed in two. Eight of the 28 children with suspected pancreatic disorders had chronic pancreatitis, five had pancreatic duct disruption, three had pancreas divisum and the rest had a normal pancreatogram (including all eight children with unexplained abdominal pain).

8%

mild exacerbation of underlying chronic pancreatitis in four, infection of a pseudocyst in one, and mild pancreatitis in one child with a choledochal cyst. The child with an infected pseudocyst (pancreatic abscess) underwent surgery.

Pfau (2002) [36]

Retrospective

USA

43

21 boys 22 girls

13.5y

Pancreatic:28

Biliary:25

other/unknown:0

94%

6%

The three complications that occurred were two cases of mild post-ERCP pancreatitis and a case of postsphincterotomy bleeding.

Vrochides (2005) [53]

Retrospective

USA

100

63 girls 37 boys

16.2y

Pancreatic:26

Biliary:74

other/unknown:0

95%

An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography–proven choledocholithiasis required ERCP for symptoms 24 hours after operation.

0%

There were no choledocholithiasis- or ERCP-related complications.

Durakbasa (2008) [19]

Retrospective

Turkey

28

15 boys 13 girls

13y

Pancreatic:7

Biliary:21

other/unknown:0

100%

ERCPs were performed for biliary pathology in 21 (75%) children and for pancreatic pathology in 7 (25%). Of these procedures, 31 (97%) ERCPs were diagnostic and a therapeutic intervention was undertaken in 20 (63%) cases. A pre-cut papillotomy with a needle knife was necessary on 6 (19%) occasions because biliary cannulation was difficult.

6%

the development of mild self-resolving pancreatitis in one patient and stent occlusion in another

Taj (2012) [46]

prospective

Pakistan

40

18 boys, 22 girls

13.6y

Pancreatic:19

Biliary:21

other/unknown:0

98%

ERCP was successful in 51 of 52 procedures. Single procedure was performed in 36 patients, where as two patients required 2 procedures and it was repeated 4 and 6 times in the remaining two patients.

1.9%

which included mild pancreatitis, whereas asymptomatic hyperamylasaemia was seen in 11% (6/52 procedures). No mortality related to ERCP occurred.

Li (2010) [28]

Retrospective

China

42

20 boys 22 girls

11.8y

Pancreatic:42

Biliary:0

other/unknown:0

91%

Five patients underwent subsequent surgery because of refractory abdominal pain after endotherapy. Of the remaining 37 patients who received therapeutic ERCP alone, abdominal pain improved in 30 (81.1%) patients, and was completely relieved in 24 (64.9%) patients during the period of follow-up.

17.3%

including mild and moderate pancreatitis (n=17) and mild cholangitis (n=2).

Keil (2010) [27]

Retrospective

Czech Republic.

104

48 boys, 56 girls

1.7y

Pancreatic:0

Biliary:104

other/unknown:0

91.3

Biliary atresia of any type was found in 51 children (53.7 %), with a sensitivity of 86 %, a specificity of 94 %, a PPV of 96 %, and a NPV of 100 %. Choledochal cysts were found in seven children (7.4 %), with a sensitivity of 100 %, a specificity of 90 %, PPV of 86 %, and NPV of 100 %. Biliary stones were found in seven patients (7.4 %). Other structural pathology was found in six patients, and no abnormality was seen in 24 patients.

0%

No severe complications occurred during or after ERCP.

Mercier (2021) [31]

Retrospective

France

271

141 boys, 130 girls

10.9y

Pancreatic:100

Biliary:171

other/unknown:0

90%

19%

12%Post ERCP pancreatitis, sepsis 5%

Deng (2021) [17]

Retrospective

China

66

35 girls, 31 boys

NA

Pancreatic:54

Biliary:19

other/unknown:19

100%

20.7%

Post ERCP pancreatitis was identified in 19 patients; there were ten mild cases, eight moderate cases, and one severe case.

Goetz (2020) [22]

Retrospective

Germany

126

56 girls, 70 boys

64 days

Pancreatic:1

Biliary:85

other/unknown:40

14.3%

Endoscopic sphincterotomy-related bleeding in 1 case

Dahale (2019) [16]

Retrospective

India

126

67 boys, 59 girls

1-15y

Pancreatic:48

Biliary:78

other/unknown:0

86%

Five of these had chronic pancreatitis, four

had choledocholithiasis, two had pancreatic duct leak while one had biliary leak

4.8%

mild pancreatitis (2), retroperitoneal duodenal perforation (2), sphincterotomyrelated bleed (2) and hypoxia (2)

Kohoutova (2019) [9]

Retrospective

Italy

38

NR

13y

Pancreatic:38

Biliary:0

other/unknown:0

100%

3%

Cholecystitis 2 cases,

Bleeding 1 case

Wen (2019) [54]

Retrospective

China

38

NR

10y

Pancreatic:38

Biliary:0

other/unknown:0

100%

14.9%

including pancreatitis of 13.5% and hemorrhage of 1.4%

Negm (2018) [32]

Retrospective

Germany

251

137 boys, 114 girls

53 days

Pancreatic:0

Biliary:251

other/unknown:0

89.2%

The intervention failed in 27 (10.8%) infants due to duodenal stenosis (n = 6), pylorus stenosis (n = 1), small papilla (n = 10), or other reasons (n =10)

0%

Cho (2017) [15]

Retrospective

Korea

198

82 boys, 116 girls

8.7y

Pancreatic:71

Biliary:127

other/unknown:0

98.9 %

Lack of procedural success was due to the inability to sedate in 1 patient and failed cannulation in 2 patients.

8.7%

5.7%Post ERCP pancreatitis, sepsis 1%, bleeding 2%

Felux (2017) [5]

Retrospective

Germany

31

15 boys, 16 girls

11y

Pancreatic:1

Biliary:20

other/unknown:10

90.7%

9.3%

included four episodes of mild pancreatitis (fever, elevation of lipase, abdominal pain).

Rosen (2017) [42]

Retrospective

USA

184

124 girls, 60 boys

8y

Pancreatic:26

Biliary:141

other/unknown:17

97%

10%

Post procedure pancreatitis occurred in 7% (n = 15), whereas hemorrhage occurred in 3% (n = 6), and duodenal perforation managed nonoperatively occurred in 0.4% (n = 1)

Yıldırım (2016) [55]

Retrospective

Turkey

48

20 girls, 28 boys

13y

Pancreatic:44

Biliary:4

other/unknown:0

70.7%

16.6 %

Post ERCP pancreatitis was the most common complication occurring in 6 patients

Bleeding occurred in 2 patients (3.1 %) and controlled with endoscopic management

Troendle (2015) [8]

Retrospective

USA

313

NR

12.7y

Pancreatic:63

Biliary:243

other/unknown:7

85.9%

10.9%

Post ERCP pancreatitis

Zhang (2020) [59]

Retrospective

China

7

3 boys, 4 girls

6.57y

Pancreatic:7

Biliary:0

other/unknown:0

100%

All seven patients were diagnosed with PPF by magnetic resonance cholangiopancreatography, and all were initially treated conservatively for a mean of 34.67 ± 22.03 d with a poor response. Among five patients who underwent ERCP, one required surgery because of intubation failure; thus, the success rate of ERCP was 80%. Two patients were successfully treated with surgery

20%

Among five patients who underwent ERCP, one required surgery because of intubation failure

Shah (2020) [44]

Retrospective

USA

110

13.3y

Pancreatic:31

Biliary:55

other/unknown:24

95%

6.1%

Post-ERCP pancreatitis occurred in 5.2% pediatric patients. Out of 12/232 patients developing PEP in pediatric age group, 3 (1.2%) had severe pancreatitis whereas 9 (3.8%) had mild pancreatitis. No need for surgical intervention and no mortality was observed. Postsphincterotomy bleeding occurred in 1.4% in pediatric patients

Zeng (2019) [58]

Retrospective

China

75

23 boys, 52 girls

6y

Pancreatic:47

Biliary:0

other/unknown:28

100%

A total of 112 ERCP procedures were performed on 75 patients with PBM (range: 1 to 5 times per patient), and the technical success rate was 100%.

16%

Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis (9/75, 12.0%), gastrointestinal bleeding (1/75, 1.3%), and infection (2/75, 2.7%).

Asenov (2019) [13]

Retrospective

Bulgaria

24

7boys, 17 girls

15y

Pancreatic:2

Biliary:10

other/unknown:12

100%

In 17 (71%) patients, the procedure was used for therapeutic purposes. The indications were choledocholithiasis (10 cases, 42%), postoperative complications (5 patients, 21%), and recurrent pancreatitis (2 cases, 8%).

4%

There were no major complications in this series. In only 1 patient, the elevation of amylase and WBC and complaints of abdominal pain were detected.

Lin (2021) [30]

Retrospective

USA

27

14 boys, 13 girls

9.7y

Pancreatic:0

Biliary:0

other/unknown:27

100%

21%

PostERCP pancreatitis (PEP)

Yu (2022) [56]

Retrospective

China

127

54 boys, 73 girls

14y

Pancreatic:13

Biliary:107

other/unknown:0

98.3%

12.2%

PostERCP pancreatitis (PEP)

Rashid (2022) [39]

Retrospective

Bangladesh

20

13 boys, 7 girls

10y

Pancreatic:9

Biliary:11

other/unknown:0

93.3%

Two successive attempts within a fortnight for a 10-year-old female patient with chronic pancreatitis (CP) failed

0%

Troendle (2022) [50]

Prospective

USA

857

NR

13.5y

Pancreatic:27.6%

Biliary:76.4%

other/unknown:0

90.5%

8%

The most commonly identified adverse events included post-ERCP pancreatitis (5%), pain not related to post-ERCP pancreatitis (1.8%), and bleeding (1.2%)

Weng (2021) [60]

Retrospective

China

15

7 boys, 8 girls

10.4y

Pancreatic:5

Biliary:10

other/unknown:0

100%

11.8%

post-ERCP pancreatitis

Pan (2021) [34]

Retrospective

China

46

24 boys, 22 girls

28.5 mon

Pancreatic:0

Biliary:0

other/unknown:46

87%

7.9%

post-ERCP pancreatitis