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

Table 1 Study characteristics in the final 128-study analysis set, n (%)

Characteristic	Finding
Included studies	128
Publication years	2017-2026
Published in 2020 or later	101 studies (78.9)
Leading data-source countries or regions	United States 32 (25.0); China 32 (25.0); multinational or international 12 (9.4); Türkiye 9 (7.0)
Most common design	Single-center retrospective study: 70 (54.7)
Other designs	Multicenter retrospective 14 (10.9); national or administrative database 12 (9.4); case series 10 (7.8); prospective, randomized, or prospective database 6 (4.7)
Extractable sample size	127 studies; median 66 (IQR: 31-147; range, 1-1124)
Extractable ERCP volume	123 studies; median 68 (IQR: 30-150; range, 1-1124)

ERCP: Endoscopic retrograde cholangiopancreatography; IQR: Interquartile range.

Table 2 Study-level classification of indications and interventions, n (%)

Category	Studies
Pancreatitis or pancreatic-duct disease	82 (64.1)
Choledocholithiasis or common bile duct stones	81 (63.3)
Congenital biliary dilatation, choledochal cyst, or pancreaticobiliary maljunction	26 (20.3)
Biliary stricture or post-transplant biliary disease	26 (20.3)
Sphincterotomy or papillotomy	72 (56.3)
Stent placement or removal	69 (53.9)
Stone extraction, lithotripsy, or duct clearance	52 (40.6)
Balloon dilation or sweeping	33 (25.8)
Biliary or nasobiliary drainage	23 (18.0)

Categories are not mutually exclusive; percentages use the 128 included studies as the denominator.

Table 3 Endpoint-specific outcome summaries

Endpoint	Usable studies (n)	Study-level summary
Technical success	49	Median 94.7% (IQR: 89.8%-97.2%; range, 24%-100%)
PEP	39	Median 5.2% (IQR: 3.0%-9.5%; range, 0%-20%)
Overall complications or adverse events	89	Median 8.9% (IQR: 3.2%-14.2%; range, 0%-50%)

Missing, ambiguous, or non-endpoint-specific text was not treated as zero-event data. PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; IQR: Interquartile range.

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.