post-ERCP Pancreatitis Research Articles

Efficacy and safety of covered versus uncovered self‑expandable metal stents for the palliative treatment of malignant distal biliary stricture: A long‑term retrospective study.

Both covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (USEMSs) have been tried in the palliation of malignant distal biliary strictures by means of endoscopic retrograde cholangiopancreatography (ERCP); however, the comparison of efficacy and safety between them remains contested. To the best of our knowledge, no similar studies have assessed this in the Chinese population. In the present study, the clinical and endoscopic data of 238 patients (CSEMSs, n=55; USEMSs, n=183) with malignant distal biliary strictures from 2014 to 2019 were collected. The efficacy indicated by mean stent patency, stent patency rate, mean patient survival time and survival rate, and the safety indicated by adverse events after CSEMS or USEMS placement were retrospectively analyzed and compared. The mean stent patency time was significantly longer in the CSEMSs group than that in the USEMSs group (262.8±195.3 days vs. 169.5±155.7 days, P=0.002). The mean patient survival time was significantly longer in the CSEMSs group than that in the USEMSs group (273.9±197.6 days vs. 184.9±167.6 days, P=0.003). The stent patency rate and patient survival rate were significantly higher in the CSEMSs group than those in the USEMSs group at 6 and 12 months, but not at 1 and 3 months. There was no significant difference in stent dysfunction and adverse events between the two groups, although post-ERCP pancreatitis (PEP) occurred more frequently in the CSEMSs group than in the USEMSs group (18.1% vs. 8.8%, P=0.049). In conclusion, CSEMSs were better than USEMSs for malignant distal biliary strictures in terms of stent patency time and patient survival time as well as stent patency rate and patient survival rate in the long term (>6 months). Adverse events in the two groups occurred at a similar rate, although the incidence of PEP was higher in the CSEMSs group.

Etiology of Pancreatitis in Patients at a Tertiary Care Center

Objective: To compare etiological frequencies in patients of acute pancreatitis presenting to our setup with international data.
 Study Design: Cross-sectional study
 Place and Duration of Study: Department of Gastroenterology, Pakistan Emirates Military Hospital & Combined Military Hospital, Rawalpindi Pakistan, from Aug 2020 to Jan 2022.
 Methodology: Patients over 12 years suffering from pancreatitis were recruited using a convenience sampling technique based upon predefined criteria for diagnosis of pancreatitis on a questionnaire. Relevant basic lab tests, including chemistries and imaging, including Ultrasound abdomen and CECT abdomen, were analyzed to establish aetiology. Data were continuously uploaded into an electronic data sheet. International Consensus Diagnostic Criteria (ICDC) algorithms were applied to diagnose autoimmune pancreatitis.
 Results: Out of 120 patients, 74(61.7%) were males, and 46(38.3%) were females. Biliary pancreatitis was the most common aetiology 50(41.7%), followed in descending order by idiopathic 36(30%), drug-induced pancreatitis (DIP) 9(7.5%), Post ERCP Pancreatitis (PEP) 8(6.7%), tumours 5(4%), Autoimmune pancreatitis (AIP), Hypertriglyceridemia and alcohol-induced pancreatitis each 2(1.7%).
 Conclusion: Biliary pancreatitis has the highest frequency, followed by idiopathic and drug-induced pancreatitis.

The Role of Intravenous Hydration in the Prevention of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis

The Role of Intravenous Hydration in the Prevention of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis.

The safety of endoscopic retrograde cholangiopancreatography (ERCP) in hepatic cirrhosis and the impact of Child-Pugh class on post-ERCP complications need to be better studied. We investigated the post-ERCP complication rates in patients with cirrhosis compared with those without cirrhosis. We conducted a literature search of relevant databases to identify studies that reported post-ERCP complications in patients with hepatic cirrhosis. Twenty-four studies comprising 28,201 patients were included. The pooled incidence of post-ERCP complications in cirrhosis was 15.5% (95% confidence interval [CI], 11.8%-19.2%; I2=96.2%), with an individual pooled incidence of pancreatitis 5.1% (95% CI, 3.1%-7.2%; I2=91.5%), bleeding 3.6% (95% CI, 2.8%-4.5%; I2=67.5%), cholangitis 2.9% (95% CI, 1.9%-3.8%; I2=83.4%), and perforation 0.3% (95% CI, 0.1%-0.5%; I2=3.7%). Patients with cirrhosis had a greater risk of post-ERCP complications (risk ratio [RR], 1.41; 95% CI, 1.16-1.71; I2=56.3%). The risk of individual odds of adverse events between cirrhosis and non-cirrhosis was as follows: pancreatitis (RR, 1.25; 95% CI, 1.06-1.48; I2=24.8%), bleeding (RR, 1.94; 95% CI, 1.59-2.37; I2=0%), cholangitis (RR, 1.15; 95% CI, 0.77-1.70; I2=12%), and perforation (RR, 1.20; 95% CI, 0.59-2.43; I2=0%). Cirrhosis is associated with an increased risk of post-ERCP pancreatitis, bleeding, and cholangitis.

An Open-Label Randomized Controlled Trial Comparing Effectiveness of Aggressive Hydration Versus High-dose Rectal Indomethacin in the Prevention of Postendoscopic Retrograde Cholangiopancreatographic Pancreatitis (AHRI-PEP).

Although rectal administration of nonsteroidal anti-inflammatory drugs is recommended as the standard pharmacologic modality to prevent postendoscopic retrograde cholangiopancreatography (ERCP) post-ERCP pancreatitis (PEP), vigorous periprocedural hydration (vHR) with lactated Ringer's solution (LR) is emerging as an effective prophylaxis modality for PEP. There has been no head-to-head comparison between these 2. This was a single-center, randomized, open-label, noninferiority, parallel-assigned, equal allocation, controlled clinical trial in a tertiary care hospital. Consecutive adults referred for ERCP, satisfying predefined inclusion criteria, underwent simple randomization and blinded allocation into 2 groups. Those allocated to vHR received intravenous LR at 3 mL/kg/h during procedure, 20 ml/kg bolus immediately afterward, and then at 3 mL/kg/h for another 8 hours. Those randomized to rectal Indomethacin received only per-rectal 100 mg suppository immediately post-ERCP. Assuming PEP of 9% in Indomethacin arm and noninferiority margin of 4%, we calculated sample size of 171 patients in each arm for 80% power and α-error 5%. Primary outcome was incidence of PEP, within 1 week, as defined by Cotton's criteria. All analysis were done by intention-to-treat. Between October, 2017 to February, 2018, 521 patients were assessed. In all, 352 were enrolled, 178 randomized to vHR, and 174 to per-rectal Indomethacin. Baseline details and ERCP outcomes were not different between 2 groups. PEP occurred in 6 (1.7%) overall, with 1 (0.6%) in hydration arm, and 5 (2.9%) in indomethacin arm; an absolute risk reduction of 2.3% (95% confidence interval: 0.9%-3.5%) and odds ratio of 0.19 (95% confidence interval: 0.02-1.65). Three patients developed severe PEP, all receiving indomethacin. vHR with LR is noninferior to postprocedure per-rectal Indomethacin for PEP prevention (ClinicalTrials.govID:NCT03629600).

The role of rectal diclofenac and aggressive hydration with Ringer's lactate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients

The role of rectal diclofenac and aggressive hydration with Ringer's lactate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients

Propensity score-matched analysis of physician-controlled wire-guided cannulation as an effective technique against difficult cannulation in endoscopic retrograde cholangiopancreatography: A retrospective study.

Advanced endoscopic retrograde cholangiopancreatography (ERCP) cannulation strategies for difficult cases could replace conventional techniques, in which assistants control guidewires. We aimed to compare the safety and efficacy of a new salvage cannulation strategy, physician-controlled wire-guided cannulation (PCWGC), with those of a conventional strategy. This retrospective study included patients with naïve papillae who underwent ERCP between January 2018 and December 2020. Patients, divided into two groups, received initial cannulation using a conventional catheter. After failed cannulation, the second attempt used PCWGC and double-guidewire technique (DGT) in the new and conventional strategy groups, respectively. Propensity score-matching (PSM) analysis compared outcomes between groups. Primary outcome included overall success rate, while secondary outcomes included cannulation time, adverse events, and cannulation difficulty subgroup analysis. The new strategy group comprised 255 (47.6%) of 536 patients who underwent ERCP. The total cannulation success rate was 98.4% (vs. 97.2%, p = 0.318), with similar post-ERCP pancreatitis (PEP) (1.8% vs. 2.4%, p = 0.64) rates. Following 1:1 PSM, 219/438 patients were allocated to both the conventional and new strategy groups, and 46 patients from the difficult cannulation subgroup were distributed evenly among groups. No difference in overall cannulation success rate existed between the groups before (97.2% vs. 98.4%) and after PSM (96.8% vs. 98.2%). The primary cannulation success rate was higher in the conventional strategy group, while the secondary cannulation success rate was higher in the new strategy group. However, the difficult cannulation subgroup PSM results showed that only the salvage cannulation success rate was significant (9/23, 39.1% vs. 18/23, 78.3%, p = 0.007). In the difficult cannulation subgroup, the salvage cannulation success rate for PCWGC was four times higher than DGT (95% confidence interval; 1.129-14.175), with no significant difference in PEP rate (p = 0.571). PCWGC demonstrated greater efficacy than the conventional salvage technique. PCWGC could be a safe and useful technique, especially for difficult biliary cannulation.

Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography.

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique. One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated. The median size of the papillary roof was 6 mm (range, 3-20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3-15 minutes). Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children: A multicenter randomized controlled trial

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children: A multicenter randomized controlled trial

Guide Wire Selection (Straight vs. Angled) in Endoscopic Retrograde Cholangiopancreatography Using a Normal Contrast Catheter Performed by a Trainee: A Single-Center Prospective Randomized Controlled Cross-Over Study.

Wire-guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is a selective biliary cannulation technique aimed at improving the successful selective biliary cannulation rate and reducing the rate of post-ERCP pancreatitis (PEP) incidence. This study aimed to evaluate the effectiveness of angled-tip guidewires (AGW) vs. straight-tip guidewires (SGW) for biliary cannulation via WGC by a trainee. We conducted a prospective, single-center, open-labeled, randomized, and controlled trial. Fifty-seven patients were enrolled in this study and assigned randomly to two groups (Group A to S and Group S to A). In this study, we started selective biliary cannulation via WGC with an AGW or an SGW for 7 min. If cannulation was unsuccessful, the other guidewire was used, and cannulation was continued for another 7 min (cross-over method). The selective biliary cannulation success rate over 14 min was significantly higher with an AGW compared with an SGW over 14 min (57.8% vs. 34.3%, p = 0.04) and for the second 7-min segment (36.4% vs. 0%, p = 0.04). No significant difference was found for adverse events such as pancreatitis between the two guidewires. Our results suggest that an AGW is recommended for WGC performed by a trainee.

Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation.

Morphology of the major duodenal papilla (MDP) influences the outcome of standard biliary cannulation. However, those data on advanced cannulation techniques are scarce. We aimed to study the impact of MDP morphology on the outcome of both standard and advanced cannulation methods. Images of naïve papilla were retrospectively reviewed and independently classified into 4 types (1: classic appearance, 2: small, 3: bulging, and 4: ridged papillae). All cannulation was started with guidewire cannulation. After failure, advanced cannulation including double guidewire (DG) and/or precut sphincterotomy (PS) was performed. Outcomes including success rate and complications were analyzed. A total 805 naïve papilla were included. The overall advanced cannulation rate was 23.2%. The MPD type 2 (OR 1.8, 95% CI 1.8-2.9) and type 4 (OR 2.1, 95% CI 1.1-3.8) required advanced cannulation technique at a higher rate than type 1. Type 3 significantly needed a higher proportion of PS when compared with type 1 (59.09% vs 27.03%, OR 3.90, 95% CI 1.51-10.06). Overall post-ERCP pancreatitis (PEP) was 8% and was not different among MDP types. PEP was significantly increased in difficult cannulation group (15.38% vs 5.71%, p-value < 0.001). Multivariate analysis demonstrated that DG independently increased risk of PEP (OR 3.6, 95% CI 2.0-6.6). MDP type 2 and type 4 were related to difficult cannulation. Although DG and PS can be used as advanced cannulation in all types, DG carries risk of PEP and PS may be preferred over DG in MDP type 3.

The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope: A multicenter retrospective international study

BackgroundDuodenoscope-related multidrug-resistant organism (MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography (ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. MethodsThis is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score (1 to 10) on performance rating of the single-use duodenoscope, and adverse event (AE) rate. ResultsA total of 66 patients (26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47 (71.2%) grade 3 and 19 (28.8%) grade 4. The technical success rate was 98.5% (65/66). Procedural duration was 64 (interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66 (1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients (6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis (PEP), 1 cholangitis and 1 bleeding. ConclusionsSingle-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.

Comparison of endoscopic retrograde cholangiopancreatography outcomes between cap-fitted forward and side viewing endoscopes in patients with Billroth II anastomosis

BackgroundThere have been no previous studies that directly compared outcomes between cap-fitted forward-viewing and side viewing endoscopes (SE). This study aimed to compare the technical success rate and occurrence of adverse events between the side viewing and cap-fitted forward-viewing endoscope (CE) groups among patients with Billroth II anatomy who underwent ERCP.MethodsThe medical records of patients with a previous history of subtotal gastrectomy using Billroth II reconstruction who underwent ERCP at Yeungnam University Hospital between January 2004 and December 2020 were reviewed retrospectively. The patients were divided into CE and SE group. Propensity score matching analysis was performed to minimize selection bias.ResultsPropensity score matching resulted in 55 matched pairs for further analysis. Patients’ characteristics were comparable in the matched cohorts. Final success rate of selective bile duct cannulation was not significantly different between the SE and CE groups (98.2% vs. 94.5%, p = 0.308). The complete CBD stone removal rate in CBD stone and successful biliary drainage rate in malignant biliary obstruction were not significantly different between the two groups. The rate of total ERCP-related adverse events was higher in the CE group than in the SE group, but the difference was not statistically significant (10.9% vs. 7.3%, p = 0.507). Among adverse events, the rate of post-ERCP pancreatitis showed higher tendency in the CE group than in the SE group (10.9% vs. 5.5%, p = 0.297).ConclusionIn conclusion, CE seems to be equally effective as SE for ERCP in patients with Billroth II anatomy. However, attention should be paid to development of post ERCP complications, especially pancreatitis, when performed by CE.

Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Prevention Is Better Than Cure.

Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Prevention Is Better Than Cure.

Fatal outcomes of endoscopy: an analysis from the coronerʼs point of view

Background and study aims This study was designed to provide a profound analysis of fatalities associated with endoscopic procedures. Methods Protocols of all autopsies performed within 20 years in a large Department of Forensic Medicine were retrospectively analyzed to identify all fatalities directly related to an endoscopic procedure. Data were further specified focusing on the type of endoscopy and the final cause of death. Results Of 22,615 autopsies performed between January 2000 and September 2019, 86 deaths were identified as complications of an endoscopic procedure. The average age of these 86 patients was 70.9 years (66.4 (range, 26-89) in males (n = 35) and 74.1 years (range, 22-94) in females (n = 51)). Endoscopic procedures included 29 endoscopic retrograde cholangeopancreatographies (ERCPs), 27 colonoscopies, 18 percutaneous endoscopic gastrostomy (PEG) tube placements, six gastroscopies, two upper endosopic ultrasonographies, and four transesophageal echocardiographies. ERCPs, colonoscopy and PEG procedures together accounted for 74 of 86 (86 %) endoscopy-related deaths. Focusing on the single procedures, post-ERCP pancreatitis (14/29, 48 %), colonoscopy-associated perforation (24/27, 89 %), and peritonitis after PEG placement (16/18, 88 %) were the most common causes of death. Conclusions Even in the thought-to-be-safe and screening endoscopic procedures fatalities do occur. This study gives an overview of endoscopy-related fatalities, stressing the role of ERCP, colonoscopy, and PEG.

The safety and efficacy of Ringer's solution loading with rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: The RESOLUTION-PEP study.

We evaluated the safety and efficacy of aggressive hydration with rectal non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). This prospective, single-arm, multicenter trial was conducted at 12 institutions between October 2020 and August 2021. We enrolled 231 patients who had intact papillae and were scheduled to undergo ERCP. All patients were administered rectal diclofenac before ERCP. They received aggressive hydration with intravenous lactated Ringer's solution in an initial bolus of 5 ml/kg at the start of ERCP, followed by 3 ml/kg/h for 8 h after the procedure. The primary outcome was the occurrence of PEP. Secondary outcomes included PEP severity, hyperamylasemia, and adverse events. The mean age of the patients was 68.8±13.7 years, and 81 patients (35.1%) were 75 years or older. Thirteen patients developed PEP (5.6%, 95% confidence interval 3.0%-9.4%). There were 11 cases (4.8%) of mild pancreatitis and two cases (0.9%) of severe pancreatitis. Forty-five patients (19.5%) developed hyperamylasemia and one patient developed non-severe peripheral edema. Aggressive hydration combined with rectal diclofenac may be a promising strategy for the prevention of PEP. Furthermore, it is safe even for older individuals.

Risk of post-ERCP pancreatitis is increased in patients with end-stage renal disease - a meta-analysis.

Risk of post-ERCP pancreatitis is increased in patients with end-stage renal disease - a meta-analysis.

Preclinical safety evaluation of calcineurin inhibitors delivered through an intraductal route to prevent post-ERCP pancreatitis demonstrates endocrine and systemic safety

ObjectiveThere is an urgent need for safe and targeted interventions to mitigate post-ERCP pancreatitis (PEP). Calcineurin inhibitors (CnIs) offer therapeutic promise as calcineurin signaling within acinar cells is a key initiating event in PEP. In previous proof-of-concept studies using experimental models, we showed that concurrent intra-pancreatic ductal administration of the CnIs, tacrolimus (Tac) or cyclosporine A (CsA) with the ERCP radiocontrast agent (RC) prevented PEP. To translate this finding clinically, we investigated potential toxic effects of intraductal delivery of a single-dose RC-CnI formulation on endocrine pancreas function and systemic toxicities in a preclinical PEP model. MethodsC57BL/6J mice underwent ductal cannulation and received a single, intra-pancreatic ductal infusion of RC or RC with Tac or CsA (treatment groups) or underwent ductal cannulation without infusion (‘sham’ group). To assess endocrine function, intraperitoneal glucose tolerance test (IPGTT) was performed at two days before infusion and on day 2 and 14 post-surgery. To evaluate off-target tissue toxicities, renal and hepatic function-related parameters including blood urea nitrogen, plasma creatinine, potassium, aspartate aminotransferase, alanine aminotransferase, and total bilirubin were measured at the same time-points as IPGTT. Histological and biochemical indicators of pancreas injury and inflammation were also evaluated. ResultsNo abnormalities in glucose metabolism, hepatic or renal function were observed on day 2 or 14 in mice administered with intraductal RC or RC with Tac or CsA. ConclusionIntraductal delivery of RC-CnI formulation was safe and well-tolerated with no significant acute or subacute endocrine or systemic toxicities, underscoring its clinical utility to prevent PEP.

Medical disputes related to advanced endoscopic procedures with endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography for the management of pancreas and biliary tract diseases.

This study aimed to evaluate the characteristics of endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography (EUS)-related adverse events (AEs) that eventually lead to medical disputes or claims on medical professional liability. Medical disputes for ERCP/EUS-related AEs filed in the Korea Medical Dispute Mediation and Arbitration Agency between April 2012 and August 2020 were evaluated using corresponding medical records. AEs were categorized into three sections: procedure-related, sedation-related, and safety-related AEs. Among a total of 34 cases, procedure-related AEs were 26 (76.5%; 12 duodenal perforations, 7 post-ERCP pancreatitis, 5 bleedings, 2 perforations combined with post-ERCP pancreatitis); sedation-related AEs were 5 (14.7%; 4 cardiac arrests, 1 desaturation), and safety-related AEs were 5 (8.8%; 1 follow-up loss for stent removal, 1 asphyxia, 1 fall). Regarding clinical outcomes, 20 (58.8%) were fatal and eventually succumbed to AEs. For the types of medical institutions, 21 cases (61.8%) occurred at tertiary or academic hospitals, and 13 (38.2%) occurred at community hospitals. The ERCP/EUS-related AEs filed in Korea Medical Dispute Mediation and Arbitration Agency showed distinct features: duodenal perforation was the most frequent AE, and clinical outcomes were fatal, resulting in at least more than permanent physical impairment.

Impact of Trainee Involvement on Pediatric ERCP Procedures: Results From the Pediatric ERCP Initiative.

This study examines the role of trainee involvement with pediatric endoscopic retrograde cholangiopancreatography (ERCP) and whether it affects the procedure's success, post-procedural adverse outcomes, and duration. A secondary analysis of the Pediatric ERCP Database Initiative, an international database, was performed. Consecutive ERCPs on children <19 years of age from 18 centers were entered prospectively into the database. In total 1124 ERCPs were entered into the database, of which 320 (28%) were performed by trainees. The results showed that the presence of trainees did not impact technical success ( P = 0.65) or adverse events rates ( P = 0.43). Rates of post-ERCP pancreatitis, pain, and bleeding were similar between groups ( P > 0.05). Fewer cases involving trainees were in the top quartile (>58 minutes) of procedural time (19% vs 26%; P = 0.02). Overall, our findings indicate trainee involvement in pediatric ERCP is safe.