Advancing Interventional Endoscopy Procedures Through Research
The Interventional Endoscopy Center continues to build and grow its expertise in using endoscopy procedures to improve care for pediatric gastroenterology patients. Led by David Vitale, MD, the center’s team is leading two new research projects.
One study funded by the National Pancreas Foundation focuses on using endoscopic ultrasound (EUS) in investigating for markers of fibrosis in early and late chronic pancreatitis. The other is a trial testing the best ways to prevent pancreatitis in children after an endoscopic retrograde cholangiopancreatography (ERCP) procedure.
“It’s a great opportunity for us on the ground floor to push things forward and learn more about doing these procedures in pediatric patients,” Vitale says. “We know we can do it safely, but there is not a lot of literature on using EUS and ERCP in children.”
Closing a Gap for Pediatric Gastroenterology Patients
Interventional endoscopy blossomed in the last 25 years. The procedures are now common for adults but are underused in children, Vitale says.
There are few pediatric gastroenterologists nationwide properly trained in EUS and ERCP. The instruments used are not optimized for children. Vitale says physicians are pushing device makers to right-size endoscopy tools and scopes for pediatrics.
Traditionally, children needing some of these procedures have been treated with invasive open or laparoscopic surgery. But early studies show that endoscopy leads to better outcomes. More doctors also are training in pediatric EUS and ERCP.
Cincinnati Children’s created its Interventional Endoscopy Center “to increase awareness about what we can do in pediatric endoscopy and to grow the opportunities for patients in our region to have access to these procedures,” Vitale says.
The center soon will include a specialized pediatric gastrointestinal endoscopy suite designed just for this type of care.
Measuring How EUS Tracks Signs of Pancreatitis
The research supported by the National Pancreas Foundation is a pilot project to “better understand how we can improve use of EUS in children,” Vitale says.
The study is a partnership with the Pancreas Center and Cincinnati Children’s radiology team. The goal is to determine if patients with chronic or recurrent pancreatitis show signs of their disease course on EUS that don’t appear on other imaging tests.
“There’s not much out there about what EUS finds in children,” Vitale says. “We are currently using adult guidelines as markers of chronic pancreatitis, so part of this project is to start defining changes we should see in pediatric patients.”
The team will compare EUS-guided pancreas images, inclusive of shear wave elastography to measure stiffness in the pancreas, to transabdominal ultrasound images, MRI images and ERCP findings and pancreas histology when available.
Vitale’s goal for the $50,000 grant is to gather preliminary patient data that can be rolled into a larger multicenter study. He is recruiting patients with recurrent and chronic pancreatitis plus control patients.
“It’s a challenge because many places don’t have the pediatric providers who do these procedures,” he says.
Preventing Post-ERCP Pancreatitis (PEP)
The biggest risk associated with ERCP for adults and children is developing pancreatitis after the procedure.
While some data exist about how to prevent PEP, some of the information contradicts itself when looked at in children when compared to adults.
For example, a multicenter retrospective study from the University of Texas Southwestern finds that some traditional interventions used in adults to prevent PEP might increase the risk of pancreatitis for children, Vitale says.
Adults usually are given rectal indomethacin, a non-steroidal anti-inflammatory drug, during the ERCP procedure. But a large retrospective study from Vitale’s team showed that indomethacin does not necessarily prevent PEP in children, Vitale says. It’s difficult to get the correct suppository dose for a child. The 50 mg rectal dose must be cut to a smaller size for children at lower weights.
Some data suggest a decreased risk of PEP by giving patients Toradol by IV. Giving the medication by IV makes it easier to give children the right dose. But is it the best way to prevent pancreatitis after ERCP?
This PEP study will help determine which treatment (if any) reduces the risk of PEP in children.
“We are consenting patients who come in for an ERCP for any reason,” Vitale says. “We randomize the patients and give a medicine that might prevent post-ERCP pancreatitis. Then we track the data and see what happens.”
Fueling a Growing Pediatric Specialty
These studies build a foundation on which the center can expand its research, Vitale says. He is the principal investigator on both projects, which also involve experts in other specialties as well as fellows.
As pediatric interventional endoscopy grows, Vitale looks forward to Cincinnati Children’s becoming a leader in training pediatric gastroenterologists to perform EUS and ERCP.
He’s also eager to expand research efforts.
“I think the work we are doing now is setting a baseline for what we will investigate in the future,” Vitale says. “We are lucky to have a large patient population. We are a good place to perform these studies because we have the necessary resources and the volume to collect meaningful data.”
(Published May 2023)
