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The ability to perform endoscopic procedures in children and newborns is a tremendous tool that has advanced the practice of pediatric gastroenterology over the past three decades. Initially, these procedures were primarily used to assess and diagnose the severity of diseases of the upper and lower gastrointestinal tract in children.
As technology and expertise have increased over time, the ability to perform “therapeutic” endoscopic procedures in children (as well as adults) has grown. The opportunity to intervene and directly treat a variety of gastrointestinal problems by endoscopy has ushered in a new era in pediatric endoscopy.
The types of procedures, devices used and techniques utilized continue to expand and require a dedicated effort to offer the most advanced endoscopic care available. Therefore, interventional endoscopists, who have additional training and expertise in performing these advanced procedures, help provide the greatest degree of safety and expertise possible.
With the recognition that each and every procedure has its own benefits and risks, the Digestive Health Institute at Children’s Hospital Colorado has developed the ATECh clinic to ensure that patients and families have ample opportunity to discuss these issues at length.
Since many times the physician or specialist recommending these advanced endoscopic procedures are not necessarily the ones actually performing the procedure, the ATECh clinic offers a venue for families to meet with the endoscopist prior to the procedure and to review the specifics of the procedure in a relaxed and unpressured environment, much in the way that patients and families would naturally expect to meet their surgeon before undergoing a surgery.
The number of advanced and therapeutic services offered through the ATECh clinic continues to expand, including many services that would otherwise require referral to an adult interventional gastroenterologist at other pediatric centers.
Endoscopic retrograde cholangiopancreatography (ERCP)
This is a very specialized type of endoscopic procedure, used to visualize the bile ducts, gallbladder and the pancreas. In the past, ERCP procedures were fairly limited to adults due to the infrequency of gallstones in children. In recent years, however, the incidence of pediatric gallstone disease has increased significantly in along with increasing rates of childhood obesity. In addition, other forms of pancreatic and biliary diseases in children, such as primary sclerosing cholangitis, chronic/recurrent pancreatitis, sphincter of Oddi dysfunction and choledochal cysts, have contributed to the need to perform ERCP procedures. Currently, there are less than 20 pediatric gastroenterologists in the U.S. who perform these procedures.
These procedures require the use of a specialized endoscope, with the camera and instruments located on the side of the endoscope tip, rather than the end, to allow better view and access to the entrance to the bile ducts, called the papilla. Once this “side-viewing” endoscope is positioned, small tubes (catheters) can be threaded though the scope and angled up into the bile ducts. Then, liquid contrast can be injected into the bile ducts and x-rays are taken to visualize these ducts to determine if there are any stones, narrowing or blockages of that need to be cleared. If so, there are a variety of interventions that can be performed to improve the flow of bile or pancreatic secretions into the intestine. These include sphincterotomy (an incision to increase the size of the opening at the papilla), stone extraction (using balloons to “sweep” the ducts clear), dilation (to stretch or expand an area of narrowing of the ducts) and stent placement (to place a small plastic tube within the duct to ensure that drainage can occur).
ERCP procedures take 45 to 90 minutes to complete. The specialists at Children’s Colorado have been performing ERCP for almost 20 years and typically perform 25 to 50 of these per year. In addition, our center offers the capability to measure the pressure at the level of the papilla (sphincter of Oddi manometry) to determine if it is excessive and potentially the cause of GI symptoms.
Single balloon small bowel enteroscopy
This advanced diagnostic procedure offers the ability to visualize the middle of the small intestine, an area not accessible with traditional upper or lower endoscopies. With the use of a longer, more flexible endoscope, coupled with a specialized overtube with a balloon at the end, the endoscopist is able to “inchworm” their way through the small intestine by repeated inflations and deflations of the balloon. If lesions are identified, they can then be removed, marked for surgeons to potentially remove at a later time or treated to stop bleeding.
Though the size of the scope may prohibit the use of this technique in infants, Children’s Colorado published the youngest recorded case, in a 3-year-old patient.
These procedures can be performed either through the mouth (antegrade) or anus (retrograde), depending on the suspected location of the lesion in question. Single balloon enteroscopy procedures may take up to two hours to perform and may require x-rays to help guide the advancement of the scope.
The most common indications for this procedure include unidentified source of GI bleeding, suspected small intestine inflammatory bowel disease, Crohn’s disease, intestinal polyps and intestinal allergic reactions. Our center began performing these procedures in 2007 and typically performs 5-10 procedures per year.
There are several conditions in which an area of the intestine is narrowed or obstructed, causing impairment in GI function or pain. Endoscopy offers the capability to reach the area of obstruction and dilate or stretch the intestine and allow unimpeded flow.
The most common site of narrowing in pediatrics is the esophagus, usually due to a anomaly present at birth, inflammation from reflux, allergy or severe ingestion.
Dilations may be performed with either a balloon catheter, threaded through the scope and inflated at the site of narrowing or bougie (a long, tapered tube of varying sizes guided to the level of narrowing). If there is significant scar tissue present as a cause of the narrowing, repeated dilations may be required to keep the area open.
If symptoms fail to improve, additional measures may be used, such as injection of steroids or application of mitomycin-c to inhibit formation of scar tissue. Use of x-rays during the procedure is common. Procedures typically take 30-60 minutes, and our center performs 70-100 of these procedures per year.
Esophageal stent placement
In certain recurring cases, which require repeated endoscopic dilations, an esophageal stent may be considered. A stent is an expandable tube that is placed at the level of narrowing to keep the area open. In this way, it performs continuous dilation of the area for up to several weeks, reducing the need for subsequent endoscopic dilations. The size, length and position of the esophageal narrowing determines whether a patient is a good candidate for stenting.
In some cases multiple stents are used, gradually increasing in size to reach the desired dilation. Patients are typically hospitalized for 1-3 days following a stent placement to ensure that everything runs smoothly with the new stent and that they are able to eat appropriately. Procedures typically take 45-60 minutes and our center performs 2-5 stenting procedures per year.
Percutaneous endoscopic gastrostomy (PEG) placement
For some children with chronic feeding problems and poor growth or nutrition, feeding tubes for nutritional support may be needed. Typically this treatment is considered after there has been a trial of supplemental feedings through a nasogastric tube (a tube threaded through the nose down into the stomach) that has shown success.
Nasogastric tubes, for obvious reasons, are not comfortable or desirable for long-term use. As a result, we may consider placement of a more durable feeding tube, passing directly through the abdomen and into the stomach, for patients with a continued need for nutritional support. These types of feeding tubes can be placed in several different ways, by different types of doctors.
At Children’s Colorado, we offer surgical placement and endoscopic placement. Patients with altered or unusual abdominal anatomy, multiple abdominal surgeries or who require additional surgical procedures (such as a fundoplication, anti-reflux surgery), placement of the feeding tube by a surgeon is typically the best option. Otherwise, endoscopic placement by a gastroenterologist offers the advantage of being less invasive, with less recovery time. The advantages and disadvantages to both types of procedures will be discussed in the clinic.
At the conclusion of this procedure, the child is left with a longer gastrostomy tube (about 6-inches) that “dangles.” Patients typically stay at least overnight after this procedure, to ensure that are tolerating feeds though the tube and are not developing any complications. After 6-12 weeks, this longer tube is removed and converted to a skin level “button” gastrostomy by a minor procedure using an IV sedative. The “button” gastrostomy feeding tubes can be periodically changed at home by parents or in a doctor’s office.
In some cases, there is a need to provide nutrition beyond the stomach, directly into the intestine. In these patients, if there is not already a gastrostomy in place, this procedure can be altered to place a gastrojejunostomy (GJ for short) feeding tube. This procedure is a bit more invasive than the plain “G tube” and may require a longer hospitalization following the procedure. The specifics of this procedure, as well as a discussion of the alternatives, should be discussed in the clinic before proceeding.
Pyloric dilation and botox injection
For patients with an impaired ability to push food from the stomach into the small intestine, endoscopic treatment of the valve (pylorus) connecting these two organs may offer relief. These patients are typically diagnosed with “delayed gastric emptying” or “gastroparesis” and often have chronic symptoms of nausea, vomiting, and/or weight loss. This condition may occur in an otherwise healthy child following a viral illness, or it may be part of an underlying genetic or metabolic disorder.
Regardless of the cause, patients who have had unsuccessful treatments with medications may be considered for endoscopic therapy. By dilating or stretching open the pyloric valve and/or injecting botox to force the valve to relax, the stomach may have an easier time emptying into the small bowel and improve symptoms. This is typically an outpatient procedure and usually requires about 30-45 minutes to perform. Our center typically performs 3-10 of these procedures per year.
Please note that there are additional interventional and therapeutic procedures performed within the Digestive Health Institute and through the ATECh Clinic, not included here.
Patients are referred to the ATECh Clinic through a variety of ways. Your child may be directly referred through your primary care provider, if they feel that a specific procedure is needed, such as tube placement, ERCP or dilation. Alternatively, your child may already be a patient seen within the Digestive Health Institute, by a pediatric gastroenterologist who may then refer you to the ATECh program for further review and discussion about the procedure before scheduling it with one of our interventional endoscopists. Similarly, some patients are referred through the Department of Pediatric Surgery if they feel specialized endoscopy is indicated, either as an alternative or in conjunction with a surgical procedure.
Scheduling visits and procedures
At this time, ATECh clinic sessions occur on the second and fourth Tuesday mornings of each month. In addition, an interventional procedure day is reserved on the second and fourth Wednesdays of each month.
This allows for patients who live outside the Denver Metro area to potentially schedule a clinic visit in conjunction with their procedure on the following day, minimizing the time and expense of multiple long-distance trips. At the time of the visit, the procedure in question will be comprehensively reviewed and, if there is not a consensus that the procedure is fully indicated or necessary, the procedure may be cancelled in ample time. If the option of joint scheduling of the clinic visit and an endoscopic procedure is applicable in your child’s case, please inquire about this at the time of scheduling so appropriate arrangements and authorizations can be obtained.
At this time, the program is directed and all procedures performed by Robert Kramer, MD. Dr. Kramer is the Director of Endoscopy at Children’s Hospital Colorado and Co-Medical Director of the Digestive Health Institute. He has been performing interventional endoscopy in children, including ERCP, since 2001. He has numerous publications in the field of interventional endoscopy and is a frequent speaker on these topics at national medical conferences. He is a member of the Endoscopy Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, as well as the American Society of Gastrointestinal Endoscopy. In the future we may add other interventional endoscopists to the ATECh program as demand increases.
Gastrointestinal Eosinophilic Diseases Program
Phone: (720) 777-7457
Pediatric Inflammatory Bowel Disease Center
Phone: (720) 777-4600
Phone: (720) 777-6669
Digestive Health Institute at Anschutz Medical Campus
Phone: (720) 777-6669
Phone: (720) 777-6181
Colorado Center for Celiac Disease
Phone: (720) 777-3825
Phone for appointments: (720) 777-6669
General Gastroenterology Program
Phone: (720) 777-6669
Phone: (720) 777-6011