Pediatric endoscopic retrograde cholangiopancreatography: A systematic review of indications, technical success, adverse events, and complication prevention

Table 4 Pediatric-adult comparison and reporting boundaries

Domain	Pediatric evidence	Adult comparison and interpretation
Indications	Pancreatitis or pancreatic-duct disease appeared in 82/128 studies (64.1%), choledocholithiasis in 81/128 (63.3%), and congenital biliary disease or post-transplant/stricture disease in 26/128 each (20.3%); malignant indications were uncommon	Adult ERCP includes a greater malignant-obstruction burden. Differences in case mix affect procedural intent, repeat intervention, and interpretation of adverse-event rates
Anesthesia, sedation, and analgesia	A complexity-matched study used general anesthesia in 84% of pediatric vs 54% of adult ERCPs. Drug-level doses were rarely reported; one 7-child transplant cohort used midazolam 5 mg plus pethidine 50 mg, with occasional fentanyl	The isolated fixed-dose regimen is not a general pediatric dosing recommendation. The available literature does not support a pooled sedative or analgesic dose
Radiation exposure	Median fluoroscopy time was 120 seconds (IQR: 60-240) in 1073 pediatric ERCPs and 4.85 minutes in a separate 385-procedure cohort; lower operator volume predicted longer exposure	Fluoroscopy time, kerma-area product, cumulative air kerma, and image count are not interchangeable. ALARA, low-dose pulsed fluoroscopy, collimation, and dose-metric documentation are appropriate safeguards
Procedure duration	One 186-procedure series reported 119 procedures (64%) lasting < 60 minutes and 67 (36%) lasting ≥ 60 minutes. Another cohort reported a mean duration of 54.2 minutes (SD = 18.7)	Definitions varied among procedure time, anesthesia time, cannulation time, and combined operative time; a pooled pediatric-adult duration comparison would therefore be invalid
PEP prophylaxis	Reported pediatric regimens included rectal indomethacin 50 mg below 30 kg and 100 mg above 30 kg (PEP 3.0% vs 9.5% without treatment), intravenous ibuprofen 10 mg/kg (maximum 800 mg), and intravenous ketorolac 0.5 mg/kg (maximum 30 mg)	Adult guidance uses a fixed 100-mg rectal NSAID dose. Pediatric evidence is weight-sensitive and study-specific; a universal pediatric regimen cannot yet be inferred
Adverse events and PEP severity	Review medians were 5.2% for PEP (39 studies) and 8.9% for overall adverse events (89 studies). In the matched study, pediatric vs adult PEP was 5.2% vs 6.9% and adverse events were 6.1% vs 10.0%. Severe PEP was approximately 1.0%-1.2% of procedures in cohorts that graded severity	Severe PEP was uncommon in reporting cohorts, but no dataset-wide incidence was calculated because severity definitions, denominators, and follow-up windows were inconsistent; unreported events were not treated as zero

Values are study-specific unless identified as review-level medians. Adult comparisons are not pooled into the pediatric distributions. ALARA: As Low As Reasonably Achievable; ERCP: Endoscopic retrograde cholangiopancreatography; IQR: Interquartile range; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; NSAID: Nonsteroidal anti-inflammatory drug.