Risk Factors for Post-ERCP Pancreatitis and Assessment of Stent Exchange Intervals in Children with Chronic Pancreatitis

Risk Factors for Post-ERCP Pancreatitis and Assessment of Stent Exchange Intervals in Children with Chronic Pancreatitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors for Post-ERCP Pancreatitis and Assessment of Stent Exchange Intervals in Children with Chronic Pancreatitis Guiping Zhao, Yaxin Wang, Guo Zhang, Chuntao Liu, Mengran Zhao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7336773/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Endoscopic retrograde pancreatic drainage (ERPD) is a first-line therapy for pediatric chronic pancreatitis (CP), but pediatric-specific risk factors for post-ERCP pancreatitis (PEP) and optimal stent exchange intervals remain undefined. Methods In this single-center retrospective study, 51 pediatric CP patients (≤ 14 years) undergoing 131 ERPD procedures (2015–2024) were enrolled. PEP was diagnosed per ESGE 2020 criteria (new/worsened abdominal pain + amylase/lipase > 3×ULN). Univariate and multivariate logistic regression identified PEP risk factors. Stent exchange intervals (≤ 6 vs. >6 months) were compared for symptoms and acute pancreatitis occurrence. Results A cohort of 51 pediatric CP patients underwent 131 successful ERPD procedures. PEP occurred in 23 procedures (17.6%), all classified as mild and managed conservatively without severe complications. Univariate and multivariate logistic regression identified that pancreaticobiliary maljunction (PBM) (OR = 5.220, 95% CI: 1.015–26.850, P = 0.048) and small stent diameter (≤ 5 Fr) (OR = 3.317, 95% CI: 1.033–10.649, P = 0.044) as independent risk factors for PEP. No significant differences were observed in interval symptoms (short-interval: 22.7% vs. long-interval: 27.6%, P = 0.693) or acute pancreatitis episodes (9.1% vs. 10.3%, P = 0.881) between groups. Conclusions PBM and small stent diameter (≤ 5 Fr) are independent risk factors for PEP in CP children. Extending stent exchange intervals beyond 6 months does not increase symptoms or acute pancreatitis risk, suggesting it may be safe to individualize replacement timing to reduce procedural burden. 1 Introduction Chronic pancreatitis (CP) in children is a rare but severely debilitating progressive inflammatory disorder. Characterized primarily by abdominal pain and malabsorption, its symptoms are often insidious and recurrent, significantly impacting child development[ 1 ]. Left untreated, CP can lead to growth retardation, irreversible pancreatic dysfunction, and an increased risk of pancreatic cancer[ 2 ]. Current management strategies center on pancreatic enzyme replacement therapy, nutritional support, and endoscopic retrograde pancreatic drainage (ERPD)[ 3 ]. Endoscopic Retrograde Cholangiopancreatography (ERCP), first introduced in 1968 for pancreatobiliary diseases, revolutionized minimally invasive diagnosis and therapy in this field[ 4 ]. Over five decades of extensive clinical application in adults has refined ERCP techniques for conditions such as choledocholithiasis, benign and malignant biliary strictures, cholangitis, pancreatitis, jaundice of unknown origin, and pancreatobiliary tumors. Consequently, the risk factors and preventive strategies for post-ERCP complications, particularly post-ERCP pancreatitis (PEP), are well-established in the adult population[ 5 ]. Its feasibility in children was demonstrated in 1976 by Waye, and ERPD now plays a crucial role in pediatric CP management[ 6 ]. This intervention effectively alleviates abdominal pain, prevents stone formation, addresses pancreatic duct strictures, and improves long-term outcomes. However, ERCP application in children presents distinct challenges. Indications predominantly involve congenital pancreatobiliary anomalies, contrasting with the adult focus on biliary diseases. Furthermore, the smaller size and delicate nature of pediatric gastrointestinal tracts increase procedural complexity, precluding direct extrapolation of adult protocols. Notably, ERPD is a primary therapeutic modality in children, differing from common adult ERCP practices. Despite this, critical knowledge gaps persist regarding pediatric-specific risk factors for PEP following stent placement[ 7 , 8 ]. Factors such as patient age, weight, and stent characteristics (length, diameter) remain inadequately investigated[ 9 ]. An additional significant clinical dilemma is the optimal interval for stent exchange. 2018 ESGE Guideline indicates if a single 10-Fr plastic stent is placed initially with symptom improvement, continuous stent placement for 1 year is recommended without routine exchange[ 10 ]. Children often require repeated ERCPs due to underlying anatomical abnormalities, yet current guidelines lack evidence-based recommendations for exchange timing[ 11 ]. While the practice of exchanging stents at 6 months is often referenced in pediatric population, its suitability remains incompletely verified[ 12 ]. To address these unresolved questions, we conducted a retrospective single-center study. We enrolled pediatric CP patients undergoing ERCP + ERPD at our institution. Using univariate and subsequent multivariate logistic regression analyses, we aimed to identify independent risk factors for PEP in children. Concurrently, through extended follow-up, we sought to determine the optimal stent exchange interval for ERPD. This study aimed to provide evidence to reduce procedure-related morbidity and optimize the management of children with CP requiring pancreatic duct stenting. 2 Methods 2.1 Research Design This study employed a single-center retrospective cohort design, enrolling pediatric patients (aged ≤ 14 years) who underwent ERCP + ERPD at the Digestive Endoscopy Center of Beijing Friendship Hospital, Capital Medical University, between January 1, 2015 and April 30, 2024. The study protocol was approved by the institutional Ethics Committee of Beijing Friendship Hospital. 2.2 Inclusion and Exclusion Criteria Inclusion Criteria (1) Pediatric patients with CP aged ≤ 14 years; (2) Cases undergoing ERCP + ERPD at the Digestive Endoscopy Center of Beijing Friendship Hospital, Capital Medical University; (3) Completion of ERCP-informed consent procedures prior to intervention. Exclusion Criteria (1) Cases refusing ERCP treatment; (2) Cases with incomplete or inaccessible clinical data. 2.3 Operational Procedures and Equipment Selection All procedures were performed with the patient in the prone position. Anesthesia was administered either via intravenous general anesthesia (IV GA) or endotracheal intubation general anesthesia (ET GA). The standard wire-guided cannulation technique was employed during the procedure. In cases of cannulation difficulty, precut sphincterotomy or other assisted cannulation techniques were utilized. Endoscopic systems and compatible accessories, including pancreatic stents, dilation bougies, and dilation balloons (manufactured by Olympus Medical Systems Corp., Tokyo, Japan), were selected based on the patient's age and clinical characteristics. The specific endoscope models used included the JF-240, JF-260V, and TGF-260V. Given the unique nature of pediatric ERCP, to minimize complications arising from operator inexperience, all pediatric ERCP procedures at our institution are exclusively performed by two highly experienced chief physicians. Both operators have each performed over 2000 ERCP procedures prior to undertaking these cases. 2.4 Diagnostic Criteria for PEP According to the 2020 European Society of Gastrointestinal Endoscopy (ESGE) Guideline on adverse events related to ERCP, the diagnostic criteria for PEP are as follows[ 5 ]: (1) Clinical Manifestation: New-onset or significantly worsened abdominal pain following ERCP. (2) Biochemical Evidence: Serum amylase or lipase levels exceeding three times the upper limit of normal (ULN) at 24 hours post-procedure. 2.5 Observation Parameters (1) Patient Demographics and Baseline Characteristics: Age, Sex/Gender, Body weight, Medical history (including relevant comorbidities). (2) Preoperative Laboratory and Imaging Findings: Preoperative biochemical profiles (e.g., liver function tests, renal function tests, electrolytes), Serum amylase levels, Coagulation function tests (e.g., prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR)), Preoperative imaging results: Abdominal ultrasound, Magnetic resonance cholangiopancreatography (MRCP), Computed tomography (CT), Electrocardiogram (ECG) findings. (3) Intraoperative Procedural Variables: Performance of endoscopic sphincterotomy (EST) (Yes/No), Removal of pre-existing pancreatic duct (PD) stent (Yes/No), Number of pancreatic duct stents placed, Length of pancreatic duct stent(s) (mm or Fr), Diameter of pancreatic duct stent(s) (Fr), Performance of balloon dilation. (4) Postoperative Clinical Symptoms: Presence and severity of: Abdominal pain, Fever, Jaundice, Nausea and/or vomiting, Other procedure-related symptoms. (5) Postoperative Laboratory Parameters: Serum testing within 24 hours post-ERCP including: Complete blood count (CBC) with differential + C-reactive protein (CRP), Comprehensive metabolic panel (electrolytes, renal/liver function), Serum amylase and/or lipase. (6) Follow-up Protocol for Pediatric Cohort: Scheduled pancreatic duct (PD) stent exchange intervals, Stent-related symptoms during follow-up periods, Incidence of acute pancreatitis (diagnosed per Revised Atlanta Criteria) 2.6 Statistical Analysis Statistical analysis was performed using SPSS 26. Normally distributed data were analyzed using the independent t-test, while non-normally distributed data were analyzed using nonparametric tests (Mann-Whitney U test). Categorical variables were analyzed using the chi-square test, and ranked/ordinal data were analyzed using the Kolmogorov-Smirnov two-sample test. Factors influencing clinical outcomes were analyzed using binary logistic regression models. The statistical significance level was set at P < 0.05. 3 Results 3.1 Clinical characteristics of the participants A total of 51 pediatric patients who underwent ERCP + ERPD at our institution were enrolled. The cohort comprised 27 males (52.9%) and 24 females (47.1%), with a marginal predominance of male patients. Other Clinical characteristics were listed in Table 1 . Table 1 Baseline characteristics of the 51 enrolled patients. Gender n (%) Male 27(52.9) Female 24(47.1) Age (years) 0–6 6(11.8) 7–11 28(54.9) 12–14 17(33.3) Height (cm) 141.8 ± 17.5 Weight (kg) 37.5 ± 14.3 BMI(kg/m²) 18.1 ± 3.5 Comorbidity Fatty liver 1 Splenomegaly 1 3.2 Endoscopic Procedures and Findings A total of 131 ERCP procedures with pancreatic duct stenting were successfully performed in 51 pediatric patients with CP (technical success rate: 100%). Nineteen patients (37.3%) underwent single stenting procedures, while 32 patients (62.7%) required two or more procedures. Endoscopic diagnoses across all procedures revealed (Table 2 ): Chronic pancreatitis: 131 procedures (100%, confirmation criterion); Other endoscopic diagnoses included: Pancreatic duct stones (6.1%), Pancreas divisum (71.8%), Pancreaticobiliary maljunction (12.2%), Pancreatic duct strictures (92.3%), Pancreatic duct fistula (0.7%), Pancreatic pseudocysts: (1.5%). Apart from ERPD, the 131 endoscopic procedures encompassed the following interventions: Endoscopic sphincterotomy (EST)(10.7%), Stent removal༈35.1%༉, Balloon dilation(6.1%), Bougienage dilation(15.3%), Pancreatic stone extraction(6.1). Table 2 Diagnostic findings and endoscopic procedures in 51 pediatric patients Diagnosis n (%) Chronic pancreatitis 131/131(100) Pancreatic duct stones 8(6.1) Pancreas divisum 94(71.8) Complete pancreas divisum 32(34.0) Incomplete pancreas divisum 62(66.0) Pancreaticobiliary maljunction 16(12.2) Pancreatic duct stricture 121(92.3) Pancreatic fistula 1(0.7) Pancreatic pseudocyst 2(1.5) Interventions EST 14(10.7) Pancreatic stent removal 46(35.1) Balloon dilation 8(6.1) Bougienage dilation 20(15.3) Pancreatic stone extraction 8(6.1) 3.3 Characteristics of Pancreatic Duct Stent Placement We defined placement of pancreatic duct stents with lengths greater than 5 cm as the Long Stent Group, and placement of stents where all were 5 cm long as the Short Stent Group. Similarly, placement of pancreatic duct stents with diameters greater than 5 Fr was defined as the Large-Caliber Stent Group, and placement of stents where all were 5 Fr in diameter as the Small-Caliber Stent Group. Statistically, the Long Stent Group comprised 108 procedures (82.4%), significantly higher than the Short Stent Group's 23 procedures (17.6%). The Large-Caliber Stent Group included 66 procedures (50.4%), while the Small-Caliber Stent Group included 65 procedures (49.6%), indicating similar procedural volumes between these two groups. One or two stents were placed during each procedure. The Single Stent Group accounted for 74 procedures (56.5%), and the Double Stent Group for 57 procedures (43.5%), with the Single Stent Group having a slightly higher number of procedures (Table 3 ). Table 3 Characteristics of endoscopically placed stents Characteristic n (%) Stent Length Long-stent group 108(82.4) Short-stent group 23(17.6) Stent Diameter Large-diameter 66(50.4) Small-diameter 65(49.6) Stent Number Single stent 74(56.5) Multiple stents 57(43.5) 3.4 Risk Factors for PEP Following Pancreatic Duct Stent Placement in Children In 131 ERCP procedures, PEP occurred in 23 cases (17.6%). No other serious complications such as bleeding or perforation occurred. All PEP cases were classified as mild pancreatitis and resolved with conservative management including acid suppression, enzyme inhibition, and nutritional support, leading to symptom improvement and successful recovery. We performed univariate and multivariate logistic regression analyses to identify risk factors for PEP following ERCP in children, incorporating all previously collected variables (Table 4 ). The regression analysis revealed that Pancreaticobiliary Maljunction(PBM) (OR: 5.220, 95%CI༚1.015–26.850, P 1 = 0.025 , P 2 = 0.048) and small stent diameter (≤ 5 Fr) (OR ༚ 3.317, 95%CI ༚ 1.033–10.649, P 1 = 0.035, P 2 = 0.044) were independent risk factors for PEP in children undergoing ERPD. No other factors were identified as independent risk factors for PEP in children undergoing ERPD. Table 4 Univariate and Multivariate Analysis of Risk Factors for Post-ERPD Pancreatitis Related factors Number of cases/total number of cases Incidence rate (%) Univariate P value( P 1) Multivariate P value( P 2) OR Gender 0.128 0.164 0.470(0.162–1.361) Male 11/81(13.6) Female 12/50(24.0) Age (years) 0.982 0.754 1.248(0.312–4.998) 0–11 4/23(17.4) 12–14 19/108(17.6) Weight 7/36(19.4) 0.727 0.486 1.517(0.470–4.895) First ERCP 5/28(17.9) 0.979 0.913 0.929(0.248–3.484) Acute pancreatitis history 14/84(16.7) 0.720 0.664 0.770(0.238–2.497) Diagnosis Complete Pancreas divisum 4/32(12.5) 0.387 0.667 0.737(0.184–2.952) Incomplete Pancreas divisum 11/62(17.7) 0.958 0.737 1.219(0.383–3.884) Pancreaticobiliary maljunction 6/16(37.5) 0.025 0.048 5.220(1.015–26.850) Endoscopic Treatment EST 2/14(14.3) 0.734 0.459 0.471(0.064–3.449) Pancreatic stent removal 6/46(13.0) 0.318 0.614 0.715(0.194–2.633) Balloon dilation 1/8(12.5) 0.698 0.735 0.656(0.057–7.548) Bougienage dilation 4/19(21.1) 0.665 0.844 1.153(0.280–4.748) Pancreatic stone extraction 2/8(25.0) 0.568 0.302 3.119(0.359–27.111) Stent length 0.562 0.778 1.241(0.278–5.547) Long-stent group 18/108(16.7) Short-stent group 5/23(21.7) Stent diameter 0.035 0.044 3.317(1.033–10.649) Large-diameter 7/66(10.6) Small-diameter 16/65(24.6) Stent number 0.352 0.922 1.063(0.314–3.595) Single stent 15/74(20.3) Multiple stents 8/57(14.0) 3.5 Symptom and Acute Pancreatitis Occurrence by Stent Exchange Interval This study followed 51 patients postoperatively, stratified into a Short-Interval Group (stent exchange ≤ 6 months, n = 22) and Long-Interval Group (> 6 months, n = 29), with median stent indwelling times of 6 months and 11 months, respectively. The primary endpoint assessed interval symptoms (persistent/worsening abdominal pain, nausea/vomiting, fever, jaundice) and acute pancreatitis episodes: 5 patients (22.7%) in the Short-Interval Group developed symptoms (1 persistent fever, 4 worsening abdominal pain with nausea/vomiting) versus 8 (27.6%) in the Long-Interval Group (4 abdominal pain, 2 abdominal pain with nausea/vomiting, 2 fever), showing no statistically significant difference ( P = 0.693); acute pancreatitis occurred in 2 vs. 3 patients, respectively, also without statistical significance ( P = 0.881)(Table 5 – 6 ). Table 5 Discomfort Symptoms After Pancreatic Duct Stent Placement Adverse symptoms 0–6 months(n = 22) > 6 months (n = 29) Persistent/worsening abdominal pain ± nausea/vomiting 4 6 Fever 1 2 Jaundice 0 0 Table 6 Comparison of Discomfort Symptoms and Acute Pancreatitis Episodes During Pancreatic Duct Stenting Between the Two Groups Acute Pancreatitis Episodes 0–6 months(n = 22) > 6 months (n = 29) p Stent indwelling time (median, range) 6(1, 6) 11(7, 21) Procedure-related symptoms 5/22 8/29 0.693 Acute pancreatitis episodes 2/22 3/29 0.881 4 Discussion ERPD is a first-line therapy for pediatric CP, yet evidence on risk factors for PEP and optimal stent exchange intervals remains limited. Current practice in children ERCP relies heavily on adult protocols, which may not address pediatric-specific challenges such as congenital pancreatobiliary anomalies and smaller ductal anatomy[ 13 , 14 ]. Our study identified two independent risk factors for PEP in children: PBM and smaller stent diameter. This will provide important reference for identifying patients at high risk of PEP and for its prevention. Moreover, extending the stent exchange interval beyond 6 months demonstrated no significant increase in symptoms or acute pancreatitis episodes compared to exchanges at ≤ 6 months. This supports strategically prolonging exchange intervals to reduce procedural burden on children and lower healthcare costs in pediatric ERCP practice. PEP is the most common complication of pediatric ERCP[ 7 , 15 ]. Many factors may affect the success rate of ERCP and the incidence of PEP such as age, endoscopist experience, and indication variations[ 16 – 18 ]. In this study, we exclusively included CP as a single disease entity and this may lead to divergent conclusions regarding risk factors of PEP compared to other studies. Our study confirms PBM as a significant contributor to PEP in CP children. PBM may elevate PEP risk through several mechanisms. Anatomic pathophysiology: PBM facilitates bile-pancreatic juice reflux, while stent placement further elevates pancreatic ductal pressure[ 19 ]; Procedural complexity: aberrant anatomy increases technical difficulty during pancreatic duct cannulation and may prolong procedure time and require repeated attempts[ 20 ]. Potential mitigation strategies include preoperative MRCP for comprehensive anatomical assessment and double-guidewire technique during the procedure. Another independent risk factor influencing PEP was pancreatic stent diameter. In our study. The proposed mechanism, based on fluid dynamics principles, is that small-diameter stents (≤ 5Fr) may exhibit insufficient drainage efficiency, leading to pancreatic duct hypertension. Another research also demonstrated the superior efficacy of 5Fr pancreatic stents over 3Fr stents in preventing PEP among high-risk patients, indicating stent diameter a more critical determinant of PEP prevention than stent length or number of stents[ 21 ]. However, a secondary analysis of randomized trial data indicates no significant association between the efficacy of prophylactic pancreatic stent placement in preventing PEP and five modifiable technical factors including stent diameter[ 22 ]. The discrepancy between our findings and this study may be attributed to: (i) distinct study population characteristics (age distribution and disease spectrum), and (ii) differences in stent placement aims (therapeutic drainage in our cohort versus pancreatitis prophylaxis in their protocol). Considering the main purpose of therapeutic drainage in pediatric patients rather than pancreatitis prophylaxis, larger-diameter stents should be considered when clinically appropriate. Other studies indicate additional PEP risk factors in children include ERCP procedural (difficult cannulation), intraoperative guidewire insertion into pancreatic duct and pancreatic disease(compared to biliary indication)[ 23 – 26 ]. However, we exclusively included CP patients and achieved technical success in all cases, association between procedural challenges, guidewire misplacement into pancreatic duct, pancreatic indications and PEP could not be validated in our study. Deep guidewire insertion into pancreatic duct may trigger pancreatitis. Due to the retrospective nature of our study, accurate intraoperative data on cannulation depth/duration were unavailable, precluding statistical analysis of this variable. Current evidence regarding prophylaxis for PEP in pediatric populations remains limited. Mark JA suggested that NSAIDs such as ketorolac may provide prophylactic value against pediatric PEP. In a randomized controlled trial by Troendle et al., intravenous ibuprofen reduced postprocedural abdominal pain risk ( P = 0.01)[ 27 ]. However, its prophylactic effect against PEP did not reach statistically significant differences (7% vs. 17%, P = 0.42)[ 28 ]. No consensus exists on optimal NSAID selection or dosing regimens for children. A key finding of this study is that pancreatic stent exchange intervals exceeding six months demonstrated no significant difference in the incidence of procedure-related symptoms or pancreatitis during follow-up, compared with exchanges at ≤ 6 months. ESGE suggests the stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months[ 10 ]. Current controversies exist between scheduled exchange (typically every 3–6 months) and symptom-driven exchange in children, but most studies supporting symptom-driven exchange are now considerably dated[ 29 , 30 ]. Despite the absence of pediatric guideline recommendations, stent replacement every 6 months is typically recommended in pediatric practice[ 31 , 32 ]. Our finding supports judiciously extending pediatric stent exchange intervals, contradicting current tacit rules. Crucially, stent exchange should not be indiscriminately prolonged in case of stent dysfunction. Considering the elevated risks of stent occlusion with small-diameter stent for a prolonged period, the higher risk of PEP as mentioned above in small-diameter group, a strategic shift toward large-diameter stent (≥ 6 Fr) with judiciously prolonged exchange intervals may be a better choice for pediatric chronic pancreatitis. While our study specifically compared > 6-month vs. ≤6-month intervals, optimal timing requires further validation prior to guideline incorporation This study has several limitations inherent to its single-center, retrospective design: Relatively limited sample size (n = 51) restricts the statistical power to detect subtler risk associations. Unavailable technical metrics (e.g., cannulation depth, procedure duration) precluded analysis of operator-dependent PEP risk factors. Besides, several unresolved questions remain regarding: the optimal stent diameter threshold for pediatric ductal anatomy, optimal timing for stent exchange and effective NSAID prophylaxis protocols (agent selection and dosing). Inconclusion, PBM and small stent diameter (≤ 5 Fr) are independent risk factors for PEP in CP children. Extending stent exchange intervals beyond 6 months does not increase symptoms or acute pancreatitis risk, suggesting it may be safe to individualize replacement timing to reduce procedural burden. Declarations Ethics approval and consent to participate The study was approved by Institutional Ethics Committee of Beijing Friendship Hospital (approval number: 2025-P2-206-02). All methods were performed in accordance with the Declaration of Helsinki. All the legal guardians of the children enrolled in the study signed informed consent forms before their child were enrolled in the study. Consent for publication Not applicable. Conflict of interest The authors declare no competing interests. Clinical trial number: Not applicable. Funding This work was supported by National Natural Science Foundation (82100570), Beijing Natural Science Foundation(7244322), and National Natural Science Foundation༈82270591༉ Author Contribution Guiping Zhao: Conceptualization, Writing – original draft. YW: Data curation, Writing – original draft. Guo Zhang: Data curation. CL: Investigation (endoscopic procedures). MZ: Funding acquisition. PL: Investigation (endoscopic procedures), Funding acquisition. QL: Conceptualization, Supervision. FL: Supervision, Funding acquisition. Acknowledgments We thank the doctors and nurses at the Endoscopy Center of Beijing Friendship Hospital for their invaluable support and assistance throughout this study. We would also like to thank all the participants in this study. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Uc A, Husain SZ. Pancreatitis in Children. Gastroenterology. 2019;156:1969–78. https://doi.org/10.1053/j.gastro.2018.12.043 . Lowenfels AB, Maisonneuve P, Cavallini G, Ammann RW, Lankisch PG, Andersen JR, Dimagno EP, Andrén-Sandberg A, Domellöf L. Pancreatitis and the risk of pancreatic cancer. 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Endoscopy. 2014;46:573–80. https://doi.org/10.1055/s-0034-1365701 . Elmunzer BJ, Zhang J, Coté GA, Edmundowicz SA, Wani S, Shah R, et al. Technical Factors Associated With the Benefit of Prophylactic Pancreatic Stent Placement During High-Risk Endoscopic Retrograde Cholangiopancreatography: A Secondary Analysis of the SVI Trial Data Set. Am J Gastroenterol. 2025;120:811–5. https://doi.org/10.14309/ajg.0000000000003052 . Yang L, Fu Y, Tang J, Sun ZH, Zhou J. Risk factors for pancreatitis after endoscopic retrograde cholangiopancreatography in children. Zhongguo Dang Dai Er Ke Za Zhi. 2024;26(07):690–4. Samanta A, Vadlapudi SS, Srivastava A, Mohindra S, Sen Sarma M, Poddar U, et al. Risk Factors for Post–Endoscopic Retrograde Cholangio-Pancreatography Pancreatitis in Children With Chronic Pancreatitis and Its Prediction Using 4-Hour Postprocedure Serum Amylase and Lipase Levels. Pancreas. 2024;53:e247–53. https://doi.org/10.1097/mpa.0000000000002296 . Yu ZP, Zhu L, Yang XP, Cao RL, Chen YX. Efficacy and safety of endoscopic retrograde cholangiopancreatography in children. Zhonghua Er Ke Za Zhi. 2022;60(12):1295–301. 10.3760/cma.j.cn112140-20221028-00918 . Chinese. Hassan AM, Lin TK, Smith MT, Hornung L, Abu-El‐Haija M, Nathan JD, et al. Risk Factors for Post‐ERCP Pancreatitis in Pediatric and Young Adult Patients. J pediatr gastroenterol nutr. 2023;76:807–12. https://doi.org/10.1097/mpg.0000000000003766 . Troendle DM, Gurram B, Huang R, Barth BA. IV Ibuprofen for Prevention of Post-ERCP Pancreatitis in Children: A Randomized Placebo‐controlled Feasibility Study. J pediatr gastroenterol nutr. 2020;70:121–6. https://doi.org/10.1097/mpg.0000000000002524 . Mark JA, Kramer RE. Ketorolac Is Safe and Associated With Lower Rate of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in Children With Pancreatic Duct Manipulation. J pediatr gastroenterol nutr. 2021;73:542–7. https://doi.org/10.1097/mpg.0000000000003252 . Delhaye M, Steenbergen WV, Cesmeli E, Pelckmans P, Putzeys V, Roeyen G et al. Belgian consensus on chronic pancreatitis in adults and children : statements on diagnosis and nutritional, medical, and surgical treatment. 2014. Treacy PJ, Worthley CS, PANCREATIC STENTS IN, THE MANAGEMENT OF CHRONIC PANCREATITIS. Aust N Z J Surg. 1996;66:210–3. https://doi.org/10.1111/j.1445-2197.1996.tb01166.x . Jeong IS, Lee SH, Oh SH, Park DH, Kim KM. Metal stents placement for refractory pancreatic duct stricture in children. WJG. 2018;24:408–14. https://doi.org/10.3748/wjg.v24.i3.408 . Oracz G, Pertkiewicz J, Kierkus J, Dadalski M, Socha J, Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis. Gastrointest Endosc. 2014;80(6):1022–9. https://doi.org/10.1016/j.gie.2014.04.001 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7336773","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514870010,"identity":"497ba5fb-b929-47f8-953f-9d1b712e0cf7","order_by":0,"name":"Guiping Zhao","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Guiping","middleName":"","lastName":"Zhao","suffix":""},{"id":514870011,"identity":"bc91f89b-dabf-4c1b-b4a0-a66446a113de","order_by":1,"name":"Yaxin Wang","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yaxin","middleName":"","lastName":"Wang","suffix":""},{"id":514870012,"identity":"eedf9323-adb8-4f70-8210-aac1b4a99280","order_by":2,"name":"Guo Zhang","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Guo","middleName":"","lastName":"Zhang","suffix":""},{"id":514870013,"identity":"2688db18-979d-45cf-9fd6-bc52266573ab","order_by":3,"name":"Chuntao Liu","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chuntao","middleName":"","lastName":"Liu","suffix":""},{"id":514870014,"identity":"64c22db2-562e-477a-a5e5-953028068476","order_by":4,"name":"Mengran Zhao","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mengran","middleName":"","lastName":"Zhao","suffix":""},{"id":514870015,"identity":"ae0f3d5a-42e2-418b-95c7-54bea2e6c2af","order_by":5,"name":"Peng Li","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Li","suffix":""},{"id":514870016,"identity":"c7bdce8d-e66a-431b-81b1-466ffa089339","order_by":6,"name":"Fujing Lv","email":"","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fujing","middleName":"","lastName":"Lv","suffix":""},{"id":514870017,"identity":"6724bde8-2abd-4111-842e-b279bd72ebc6","order_by":7,"name":"Qianyun Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACPmYgkQBmMh/4AKLY2AloYUNoYUucARfBqwXB5DGcAbGNkBZ23oM3HtTcSdxwu+djw8e2bfJApzJ++JiDz2F8yRYJx54lbrhzdmPjjDO3DduYGZglZ27Dp4XHTCKB7XDihhu52x/zVNxmBGphY+YlqOUfSEvOw2Yeg9v2xGlJbANrYWwG2pJIjBZji8S+w8Yzb6QZgvyS3MbM2IzXL/z8Zwxv/vh2WLbvRvJDYIjdtp3f3nzww0c8WkBAAogdGxB8xgYcClG12BNUNQpGwSgYBSMXAAC0l1BUeO7AvQAAAABJRU5ErkJggg==","orcid":"","institution":"Beijing Friendship Hospital Affiliated to Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Qianyun","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2025-08-10 04:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7336773/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7336773/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91362486,"identity":"02a02ffc-80c8-4852-a9b5-36f0e55c482f","added_by":"auto","created_at":"2025-09-15 16:41:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1113092,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7336773/v1/a7b98707-524e-407e-817d-4157fd591527.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk Factors for Post-ERCP Pancreatitis and Assessment of Stent Exchange Intervals in Children with Chronic Pancreatitis","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eChronic pancreatitis (CP) in children is a rare but severely debilitating progressive inflammatory disorder. Characterized primarily by abdominal pain and malabsorption, its symptoms are often insidious and recurrent, significantly impacting child development[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Left untreated, CP can lead to growth retardation, irreversible pancreatic dysfunction, and an increased risk of pancreatic cancer[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Current management strategies center on pancreatic enzyme replacement therapy, nutritional support, and endoscopic retrograde pancreatic drainage (ERPD)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEndoscopic Retrograde Cholangiopancreatography (ERCP), first introduced in 1968 for pancreatobiliary diseases, revolutionized minimally invasive diagnosis and therapy in this field[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Over five decades of extensive clinical application in adults has refined ERCP techniques for conditions such as choledocholithiasis, benign and malignant biliary strictures, cholangitis, pancreatitis, jaundice of unknown origin, and pancreatobiliary tumors. Consequently, the risk factors and preventive strategies for post-ERCP complications, particularly post-ERCP pancreatitis (PEP), are well-established in the adult population[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Its feasibility in children was demonstrated in 1976 by Waye, and ERPD now plays a crucial role in pediatric CP management[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This intervention effectively alleviates abdominal pain, prevents stone formation, addresses pancreatic duct strictures, and improves long-term outcomes.\u003c/p\u003e\u003cp\u003eHowever, ERCP application in children presents distinct challenges. Indications predominantly involve congenital pancreatobiliary anomalies, contrasting with the adult focus on biliary diseases. Furthermore, the smaller size and delicate nature of pediatric gastrointestinal tracts increase procedural complexity, precluding direct extrapolation of adult protocols. Notably, ERPD is a primary therapeutic modality in children, differing from common adult ERCP practices. Despite this, critical knowledge gaps persist regarding pediatric-specific risk factors for PEP following stent placement[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Factors such as patient age, weight, and stent characteristics (length, diameter) remain inadequately investigated[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. An additional significant clinical dilemma is the optimal interval for stent exchange. 2018 ESGE Guideline indicates if a single 10-Fr plastic stent is placed initially with symptom improvement, continuous stent placement for 1 year is recommended without routine exchange[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Children often require repeated ERCPs due to underlying anatomical abnormalities, yet current guidelines lack evidence-based recommendations for exchange timing[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While the practice of exchanging stents at 6 months is often referenced in pediatric population, its suitability remains incompletely verified[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address these unresolved questions, we conducted a retrospective single-center study. We enrolled pediatric CP patients undergoing ERCP\u0026thinsp;+\u0026thinsp;ERPD at our institution. Using univariate and subsequent multivariate logistic regression analyses, we aimed to identify independent risk factors for PEP in children. Concurrently, through extended follow-up, we sought to determine the optimal stent exchange interval for ERPD. This study aimed to provide evidence to reduce procedure-related morbidity and optimize the management of children with CP requiring pancreatic duct stenting.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Research Design\u003c/h2\u003e\u003cp\u003eThis study employed a single-center retrospective cohort design, enrolling pediatric patients (aged\u0026thinsp;\u0026le;\u0026thinsp;14 years) who underwent ERCP\u0026thinsp;+\u0026thinsp;ERPD at the Digestive Endoscopy Center of Beijing Friendship Hospital, Capital Medical University, between January 1, 2015 and April 30, 2024. The study protocol was approved by the institutional Ethics Committee of Beijing Friendship Hospital.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Inclusion and Exclusion Criteria\u003c/h2\u003e\u003cp\u003eInclusion Criteria\u003c/p\u003e\u003cp\u003e(1) Pediatric patients with CP aged\u0026thinsp;\u0026le;\u0026thinsp;14 years;\u003c/p\u003e\u003cp\u003e(2) Cases undergoing ERCP\u0026thinsp;+\u0026thinsp;ERPD at the Digestive Endoscopy Center of Beijing Friendship Hospital, Capital Medical University;\u003c/p\u003e\u003cp\u003e(3) Completion of ERCP-informed consent procedures prior to intervention.\u003c/p\u003e\u003cp\u003eExclusion Criteria\u003c/p\u003e\u003cp\u003e(1) Cases refusing ERCP treatment;\u003c/p\u003e\u003cp\u003e(2) Cases with incomplete or inaccessible clinical data.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Operational Procedures and Equipment Selection\u003c/h2\u003e\u003cp\u003eAll procedures were performed with the patient in the prone position. Anesthesia was administered either via intravenous general anesthesia (IV GA) or endotracheal intubation general anesthesia (ET GA). The standard wire-guided cannulation technique was employed during the procedure. In cases of cannulation difficulty, precut sphincterotomy or other assisted cannulation techniques were utilized. Endoscopic systems and compatible accessories, including pancreatic stents, dilation bougies, and dilation balloons (manufactured by Olympus Medical Systems Corp., Tokyo, Japan), were selected based on the patient's age and clinical characteristics. The specific endoscope models used included the JF-240, JF-260V, and TGF-260V. Given the unique nature of pediatric ERCP, to minimize complications arising from operator inexperience, all pediatric ERCP procedures at our institution are exclusively performed by two highly experienced chief physicians. Both operators have each performed over 2000 ERCP procedures prior to undertaking these cases.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Diagnostic Criteria for PEP\u003c/h2\u003e\u003cp\u003eAccording to the 2020 European Society of Gastrointestinal Endoscopy (ESGE) Guideline on adverse events related to ERCP, the diagnostic criteria for PEP are as follows[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]:\u003c/p\u003e\u003cp\u003e(1) Clinical Manifestation: New-onset or significantly worsened abdominal pain following ERCP.\u003c/p\u003e\u003cp\u003e(2) Biochemical Evidence: Serum amylase or lipase levels exceeding three times the upper limit of normal (ULN) at 24 hours post-procedure.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Observation Parameters\u003c/h2\u003e\u003cp\u003e(1) Patient Demographics and Baseline Characteristics: Age, Sex/Gender, Body weight, Medical history (including relevant comorbidities).\u003c/p\u003e\u003cp\u003e(2) Preoperative Laboratory and Imaging Findings: Preoperative biochemical profiles (e.g., liver function tests, renal function tests, electrolytes), Serum amylase levels, Coagulation function tests (e.g., prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR)), Preoperative imaging results: Abdominal ultrasound, Magnetic resonance cholangiopancreatography (MRCP), Computed tomography (CT), Electrocardiogram (ECG) findings.\u003c/p\u003e\u003cp\u003e(3) Intraoperative Procedural Variables: Performance of endoscopic sphincterotomy (EST) (Yes/No), Removal of pre-existing pancreatic duct (PD) stent (Yes/No), Number of pancreatic duct stents placed, Length of pancreatic duct stent(s) (mm or Fr), Diameter of pancreatic duct stent(s) (Fr), Performance of balloon dilation.\u003c/p\u003e\u003cp\u003e(4) Postoperative Clinical Symptoms: Presence and severity of: Abdominal pain, Fever, Jaundice, Nausea and/or vomiting, Other procedure-related symptoms.\u003c/p\u003e\u003cp\u003e(5) Postoperative Laboratory Parameters: Serum testing within 24 hours post-ERCP including: Complete blood count (CBC) with differential\u0026thinsp;+\u0026thinsp;C-reactive protein (CRP), Comprehensive metabolic panel (electrolytes, renal/liver function), Serum amylase and/or lipase.\u003c/p\u003e\u003cp\u003e(6) Follow-up Protocol for Pediatric Cohort: Scheduled pancreatic duct (PD) stent exchange intervals, Stent-related symptoms during follow-up periods, Incidence of acute pancreatitis (diagnosed per Revised Atlanta Criteria)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using SPSS 26. Normally distributed data were analyzed using the independent t-test, while non-normally distributed data were analyzed using nonparametric tests (Mann-Whitney U test). Categorical variables were analyzed using the chi-square test, and ranked/ordinal data were analyzed using the Kolmogorov-Smirnov two-sample test. Factors influencing clinical outcomes were analyzed using binary logistic regression models. The statistical significance level was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Clinical characteristics of the participants\u003c/h2\u003e\u003cp\u003eA total of 51 pediatric patients who underwent ERCP\u0026thinsp;+\u0026thinsp;ERPD at our institution were enrolled. The cohort comprised 27 males (52.9%) and 24 females (47.1%), with a marginal predominance of male patients. Other Clinical characteristics were listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of the 51 enrolled patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27(52.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24(47.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(11.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u0026ndash;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28(54.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e141.8\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI(kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFatty liver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSplenomegaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Endoscopic Procedures and Findings\u003c/h2\u003e\u003cp\u003eA total of 131 ERCP procedures with pancreatic duct stenting were successfully performed in 51 pediatric patients with CP (technical success rate: 100%). Nineteen patients (37.3%) underwent single stenting procedures, while 32 patients (62.7%) required two or more procedures. Endoscopic diagnoses across all procedures revealed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): Chronic pancreatitis: 131 procedures (100%, confirmation criterion); Other endoscopic diagnoses included: Pancreatic duct stones (6.1%), Pancreas divisum (71.8%), Pancreaticobiliary maljunction (12.2%), Pancreatic duct strictures (92.3%), Pancreatic duct fistula (0.7%), Pancreatic pseudocysts: (1.5%). Apart from ERPD, the 131 endoscopic procedures encompassed the following interventions: Endoscopic sphincterotomy (EST)(10.7%), Stent removal༈35.1%༉, Balloon dilation(6.1%), Bougienage dilation(15.3%), Pancreatic stone extraction(6.1).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDiagnostic findings and endoscopic procedures in 51 pediatric patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e131/131(100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic duct stones\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(6.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreas divisum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94(71.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplete pancreas divisum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32(34.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncomplete pancreas divisum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62(66.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreaticobiliary maljunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(12.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic duct stricture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121(92.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic pseudocyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(1.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInterventions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEST\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(10.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic stent removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46(35.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBalloon dilation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(6.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBougienage dilation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(15.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic stone extraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(6.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Characteristics of Pancreatic Duct Stent Placement\u003c/h2\u003e\u003cp\u003eWe defined placement of pancreatic duct stents with lengths greater than 5 cm as the Long Stent Group, and placement of stents where all were 5 cm long as the Short Stent Group. Similarly, placement of pancreatic duct stents with diameters greater than 5 Fr was defined as the Large-Caliber Stent Group, and placement of stents where all were 5 Fr in diameter as the Small-Caliber Stent Group. Statistically, the Long Stent Group comprised 108 procedures (82.4%), significantly higher than the Short Stent Group's 23 procedures (17.6%). The Large-Caliber Stent Group included 66 procedures (50.4%), while the Small-Caliber Stent Group included 65 procedures (49.6%), indicating similar procedural volumes between these two groups. One or two stents were placed during each procedure. The Single Stent Group accounted for 74 procedures (56.5%), and the Double Stent Group for 57 procedures (43.5%), with the Single Stent Group having a slightly higher number of procedures (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of endoscopically placed stents\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eCharacteristic n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eStent Length\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLong-stent group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e108(82.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShort-stent group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23(17.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStent Diameter\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLarge-diameter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66(50.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSmall-diameter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65(49.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStent Number\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle stent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74(56.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultiple stents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57(43.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Risk Factors for PEP Following Pancreatic Duct Stent Placement in Children\u003c/h2\u003e\u003cp\u003eIn 131 ERCP procedures, PEP occurred in 23 cases (17.6%). No other serious complications such as bleeding or perforation occurred. All PEP cases were classified as mild pancreatitis and resolved with conservative management including acid suppression, enzyme inhibition, and nutritional support, leading to symptom improvement and successful recovery. We performed univariate and multivariate logistic regression analyses to identify risk factors for PEP following ERCP in children, incorporating all previously collected variables (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The regression analysis revealed that Pancreaticobiliary Maljunction(PBM) (OR: 5.220, 95%CI༚1.015\u0026ndash;26.850, \u003cem\u003eP\u003c/em\u003e1\u0026thinsp;=\u0026thinsp;0.025 ,\u003cem\u003eP\u003c/em\u003e2\u0026thinsp;=\u0026thinsp;0.048) and small stent diameter (\u0026le;\u0026thinsp;5 Fr) (OR ༚ 3.317, 95%CI ༚ 1.033\u0026ndash;10.649, \u003cem\u003eP\u003c/em\u003e1\u0026thinsp;=\u0026thinsp;0.035,\u003cem\u003eP\u003c/em\u003e2\u0026thinsp;=\u0026thinsp;0.044) were independent risk factors for PEP in children undergoing ERPD. No other factors were identified as independent risk factors for PEP in children undergoing ERPD.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnivariate and Multivariate Analysis of Risk Factors for Post-ERPD Pancreatitis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelated factors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of cases/total number of cases Incidence rate (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnivariate \u003cem\u003eP\u003c/em\u003e value(\u003cem\u003eP\u003c/em\u003e1)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMultivariate \u003cem\u003eP\u003c/em\u003e value(\u003cem\u003eP\u003c/em\u003e2)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.470(0.162\u0026ndash;1.361)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11/81(13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12/50(24.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.982\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.754\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.248(0.312\u0026ndash;4.998)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4/23(17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19/108(17.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7/36(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.486\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.517(0.470\u0026ndash;4.895)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst ERCP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5/28(17.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.979\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.913\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.929(0.248\u0026ndash;3.484)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute pancreatitis history\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14/84(16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.720\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.664\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.770(0.238\u0026ndash;2.497)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplete Pancreas divisum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4/32(12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.387\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.667\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.737(0.184\u0026ndash;2.952)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncomplete Pancreas divisum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11/62(17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.958\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.737\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.219(0.383\u0026ndash;3.884)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreaticobiliary maljunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6/16(37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.220(1.015\u0026ndash;26.850)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEndoscopic Treatment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEST\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2/14(14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.734\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.459\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.471(0.064\u0026ndash;3.449)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic stent removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6/46(13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.318\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.614\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.715(0.194\u0026ndash;2.633)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBalloon dilation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1/8(12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.698\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.735\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.656(0.057\u0026ndash;7.548)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBougienage dilation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4/19(21.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.665\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.844\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.153(0.280\u0026ndash;4.748)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatic stone extraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2/8(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.568\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.119(0.359\u0026ndash;27.111)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStent length\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.562\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.778\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.241(0.278\u0026ndash;5.547)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLong-stent group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18/108(16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShort-stent group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5/23(21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStent diameter\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.317(1.033\u0026ndash;10.649)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLarge-diameter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7/66(10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmall-diameter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16/65(24.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStent number\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.922\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.063(0.314\u0026ndash;3.595)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle stent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15/74(20.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiple stents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8/57(14.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Symptom and Acute Pancreatitis Occurrence by Stent Exchange Interval\u003c/h2\u003e\u003cp\u003eThis study followed 51 patients postoperatively, stratified into a Short-Interval Group (stent exchange\u0026thinsp;\u0026le;\u0026thinsp;6 months, n\u0026thinsp;=\u0026thinsp;22) and Long-Interval Group (\u0026gt;\u0026thinsp;6 months, n\u0026thinsp;=\u0026thinsp;29), with median stent indwelling times of 6 months and 11 months, respectively. The primary endpoint assessed interval symptoms (persistent/worsening abdominal pain, nausea/vomiting, fever, jaundice) and acute pancreatitis episodes: 5 patients (22.7%) in the Short-Interval Group developed symptoms (1 persistent fever, 4 worsening abdominal pain with nausea/vomiting) versus 8 (27.6%) in the Long-Interval Group (4 abdominal pain, 2 abdominal pain with nausea/vomiting, 2 fever), showing no statistically significant difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.693); acute pancreatitis occurred in 2 vs. 3 patients, respectively, also without statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.881)(Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDiscomfort Symptoms After Pancreatic Duct Stent Placement\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdverse symptoms\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;6 months(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;6 months (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePersistent/worsening abdominal pain\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;nausea/vomiting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFever\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eJaundice\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Discomfort Symptoms and Acute Pancreatitis Episodes During Pancreatic Duct Stenting Between the Two Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute Pancreatitis Episodes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;6 months(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;6 months (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStent indwelling time (median, range)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(1, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(7, 21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProcedure-related symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5/22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8/29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.693\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcute pancreatitis episodes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2/22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3/29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.881\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eERPD is a first-line therapy for pediatric CP, yet evidence on risk factors for PEP and optimal stent exchange intervals remains limited. Current practice in children ERCP relies heavily on adult protocols, which may not address pediatric-specific challenges such as congenital pancreatobiliary anomalies and smaller ductal anatomy[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our study identified two independent risk factors for PEP in children: PBM and smaller stent diameter. This will provide important reference for identifying patients at high risk of PEP and for its prevention. Moreover, extending the stent exchange interval beyond 6 months demonstrated no significant increase in symptoms or acute pancreatitis episodes compared to exchanges at \u0026le;\u0026thinsp;6 months. This supports strategically prolonging exchange intervals to reduce procedural burden on children and lower healthcare costs in pediatric ERCP practice.\u003c/p\u003e\u003cp\u003ePEP is the most common complication of pediatric ERCP[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Many factors may affect the success rate of ERCP and the incidence of PEP such as age, endoscopist experience, and indication variations[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In this study, we exclusively included CP as a single disease entity and this may lead to divergent conclusions regarding risk factors of PEP compared to other studies. Our study confirms PBM as a significant contributor to PEP in CP children. PBM may elevate PEP risk through several mechanisms. Anatomic pathophysiology: PBM facilitates bile-pancreatic juice reflux, while stent placement further elevates pancreatic ductal pressure[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; Procedural complexity: aberrant anatomy increases technical difficulty during pancreatic duct cannulation and may prolong procedure time and require repeated attempts[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Potential mitigation strategies include preoperative MRCP for comprehensive anatomical assessment and double-guidewire technique during the procedure.\u003c/p\u003e\u003cp\u003eAnother independent risk factor influencing PEP was pancreatic stent diameter. In our study. The proposed mechanism, based on fluid dynamics principles, is that small-diameter stents (\u0026le;\u0026thinsp;5Fr) may exhibit insufficient drainage efficiency, leading to pancreatic duct hypertension. Another research also demonstrated the superior efficacy of 5Fr pancreatic stents over 3Fr stents in preventing PEP among high-risk patients, indicating stent diameter a more critical determinant of PEP prevention than stent length or number of stents[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, a secondary analysis of randomized trial data indicates no significant association between the efficacy of prophylactic pancreatic stent placement in preventing PEP and five modifiable technical factors including stent diameter[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The discrepancy between our findings and this study may be attributed to: (i) distinct study population characteristics (age distribution and disease spectrum), and (ii) differences in stent placement aims (therapeutic drainage in our cohort versus pancreatitis prophylaxis in their protocol). Considering the main purpose of therapeutic drainage in pediatric patients rather than pancreatitis prophylaxis, larger-diameter stents should be considered when clinically appropriate.\u003c/p\u003e\u003cp\u003eOther studies indicate additional PEP risk factors in children include ERCP procedural (difficult cannulation), intraoperative guidewire insertion into pancreatic duct and pancreatic disease(compared to biliary indication)[\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, we exclusively included CP patients and achieved technical success in all cases, association between procedural challenges, guidewire misplacement into pancreatic duct, pancreatic indications and PEP could not be validated in our study. Deep guidewire insertion into pancreatic duct may trigger pancreatitis. Due to the retrospective nature of our study, accurate intraoperative data on cannulation depth/duration were unavailable, precluding statistical analysis of this variable. Current evidence regarding prophylaxis for PEP in pediatric populations remains limited. Mark JA suggested that NSAIDs such as ketorolac may provide prophylactic value against pediatric PEP. In a randomized controlled trial by Troendle et al., intravenous ibuprofen reduced postprocedural abdominal pain risk (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01)[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, its prophylactic effect against PEP did not reach statistically significant differences (7% vs. 17%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.42)[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. No consensus exists on optimal NSAID selection or dosing regimens for children.\u003c/p\u003e\u003cp\u003eA key finding of this study is that pancreatic stent exchange intervals exceeding six months demonstrated no significant difference in the incidence of procedure-related symptoms or pancreatitis during follow-up, compared with exchanges at \u0026le;\u0026thinsp;6 months. ESGE suggests the stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Current controversies exist between scheduled exchange (typically every 3\u0026ndash;6 months) and symptom-driven exchange in children, but most studies supporting symptom-driven exchange are now considerably dated[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Despite the absence of pediatric guideline recommendations, stent replacement every 6 months is typically recommended in pediatric practice[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Our finding supports judiciously extending pediatric stent exchange intervals, contradicting current tacit rules. Crucially, stent exchange should not be indiscriminately prolonged in case of stent dysfunction. Considering the elevated risks of stent occlusion with small-diameter stent for a prolonged period, the higher risk of PEP as mentioned above in small-diameter group, a strategic shift toward large-diameter stent (\u0026ge;\u0026thinsp;6 Fr) with judiciously prolonged exchange intervals may be a better choice for pediatric chronic pancreatitis. While our study specifically compared\u0026thinsp;\u0026gt;\u0026thinsp;6-month vs. \u0026le;6-month intervals, optimal timing requires further validation prior to guideline incorporation\u003c/p\u003e\u003cp\u003eThis study has several limitations inherent to its single-center, retrospective design: Relatively limited sample size (n\u0026thinsp;=\u0026thinsp;51) restricts the statistical power to detect subtler risk associations. Unavailable technical metrics (e.g., cannulation depth, procedure duration) precluded analysis of operator-dependent PEP risk factors. Besides, several unresolved questions remain regarding: the optimal stent diameter threshold for pediatric ductal anatomy, optimal timing for stent exchange and effective NSAID prophylaxis protocols (agent selection and dosing).\u003c/p\u003e\u003cp\u003eInconclusion, PBM and small stent diameter (\u0026le;\u0026thinsp;5 Fr) are independent risk factors for PEP in CP children. Extending stent exchange intervals beyond 6 months does not increase symptoms or acute pancreatitis risk, suggesting it may be safe to individualize replacement timing to reduce procedural burden.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The study was approved by Institutional Ethics Committee of Beijing Friendship Hospital (approval number: 2025-P2-206-02). All methods were performed in accordance with the Declaration of Helsinki. All the legal guardians of the children enrolled in the study signed informed consent forms before their child were enrolled in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical trial number:\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by National Natural Science Foundation (82100570), Beijing Natural Science Foundation(7244322), and National Natural Science Foundation༈82270591༉\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGuiping Zhao: Conceptualization, Writing \u0026ndash; original draft. YW: Data curation, Writing \u0026ndash; original draft. Guo Zhang: Data curation. CL: Investigation (endoscopic procedures). MZ: Funding acquisition. PL: Investigation (endoscopic procedures), Funding acquisition. QL: Conceptualization, Supervision. FL: Supervision, Funding acquisition.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e\u003cp\u003eWe thank the doctors and nurses at the Endoscopy Center of Beijing Friendship Hospital for their invaluable support and assistance throughout this study. We would also like to thank all the participants in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUc A, Husain SZ. Pancreatitis in Children. 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Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis. Gastrointest Endosc. 2014;80(6):1022\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.gie.2014.04.001\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2014.04.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7336773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7336773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEndoscopic retrograde pancreatic drainage (ERPD) is a first-line therapy for pediatric chronic pancreatitis (CP), but pediatric-specific risk factors for post-ERCP pancreatitis (PEP) and optimal stent exchange intervals remain undefined.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this single-center retrospective study, 51 pediatric CP patients (\u0026le;\u0026thinsp;14 years) undergoing 131 ERPD procedures (2015\u0026ndash;2024) were enrolled. PEP was diagnosed per ESGE 2020 criteria (new/worsened abdominal pain\u0026thinsp;+\u0026thinsp;amylase/lipase\u0026thinsp;\u0026gt;\u0026thinsp;3\u0026times;ULN). Univariate and multivariate logistic regression identified PEP risk factors. Stent exchange intervals (\u0026le;\u0026thinsp;6 vs. \u0026gt;6 months) were compared for symptoms and acute pancreatitis occurrence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA cohort of 51 pediatric CP patients underwent 131 successful ERPD procedures. PEP occurred in 23 procedures (17.6%), all classified as mild and managed conservatively without severe complications. Univariate and multivariate logistic regression identified that pancreaticobiliary maljunction (PBM) (OR\u0026thinsp;=\u0026thinsp;5.220, 95% CI: 1.015\u0026ndash;26.850, \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.048) and small stent diameter (\u0026le;\u0026thinsp;5 Fr) (OR\u0026thinsp;=\u0026thinsp;3.317, 95% CI: 1.033\u0026ndash;10.649, \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.044) as independent risk factors for PEP. No significant differences were observed in interval symptoms (short-interval: 22.7% vs. long-interval: 27.6%, \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.693) or acute pancreatitis episodes (9.1% vs. 10.3%, \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.881) between groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePBM and small stent diameter (\u0026le;\u0026thinsp;5 Fr) are independent risk factors for PEP in CP children. Extending stent exchange intervals beyond 6 months does not increase symptoms or acute pancreatitis risk, suggesting it may be safe to individualize replacement timing to reduce procedural burden.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Post-ERCP Pancreatitis and Assessment of Stent Exchange Intervals in Children with Chronic Pancreatitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 16:25:04","doi":"10.21203/rs.3.rs-7336773/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T01:43:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T07:30:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-03-24T02:18:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-25T16:32:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222221933419645709515900695062412546568","date":"2025-10-23T19:50:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107294794427083362844795480354422303149","date":"2025-10-21T13:14:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T13:48:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-22T08:24:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-22T04:21:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T04:19:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-08-10T04:34:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa9dcd22-a6d6-45fc-815f-1d1e6f3e937e","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T08:51:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 16:25:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7336773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7336773","identity":"rs-7336773","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}