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OBJECTIVE Total pancreatectomy with islet autotransplantation (TPIAT) is indicated to alleviate debilitating pancreas-related pain and mitigate diabetes in patients with acute recurrent and chronic pancreatitis when medical/endoscopic therapies fail. Our aim was to evaluate predictors of insulin requirement at 1 year following TPIAT in a cohort of children. RESEARCH DESIGN AND METHODS This was a review of 43 pediatric patients followed after TPIAT for 1 year or longer. Primary outcome was insulin use at 1 year, categorized as follows: insulin independent, low insulin requirement ( RESULTS At 1 year after TPIAT, 12 of 41 (29%) patients were insulin independent and 21 of 41 (51%) had low and 8 of 41 (20%) had high insulin requirement. Insulin-independent patients were younger than those with low and high insulin requirement (median age 8.2 vs. 14.6 vs. 13.1 years, respectively; P = 0.03). Patients with insulin independence had a higher number of transplanted islet equivalents (IEQ) per kilogram body weight (P = 0.03) and smaller body surface area (P = 0.02), compared with those with insulin dependence. Preoperative exocrine insufficiency was associated with high insulin requirement (P = 0.03). Higher peak C-peptide measured by stimulated mixed-meal tolerance testing (MMTT) at 3 and 6 months post-TPIAT was predictive of lower insulin requirement at 1 year (P = 0.006 and 0.03, respectively). CONCLUSIONS We conclude that insulin independence following pediatric TPIAT is multifactorial and associated with younger age, higher IEQ per kilogram body weight transplanted, and smaller body surface area at time of operation. Higher peak C-peptide measured by MMTT following TPIAT confers a higher likelihood of low insulin requirement.

BACKGROUND AND AIMS Endoscopic mucosal resection (EMR) for removal of large polyps is well established in adults. EMR technique in the pediatric population is less utilized due to lower incidence of large intestinal polyps in pediatric patients and limited EMR training for pediatric gastroenterologists. The aim of this study is to retrospectively review safety and efficacy of pediatric EMR cases at two large, tertiary referral centers with adult and pediatric EMR expertise. METHODS A retrospective chart review was conducted at Cedars-Sinai Medical Center and Cincinnati Children's Hospital Medical Center from January 2012 to May 2021. Demographic, clinical, technical and follow up data were collected for patients

Hepatic steatosis has been described as a common finding in adults following total pancreatectomy with islet autotransplantation (TPIAT) but it is unknown if this occurs in children and adolescents.To define the frequency of post-TPIAT hepatic steatosis in a sample of children and adolescents and to identify clinical predictors of incident steatosis post-TPIAT.In this prospective study, consecutive participants at least 1-month post-TPIAT underwent a liver MRI with proton density fat fraction (PDFF) and blood draw at our pediatric academic medical center between April 2021 and January 2022. Comparison clinical pre-TPIAT liver MRI or ultrasound and insulin use and graft function data were extracted from the medical record. T-tests were used for the comparison of means across continuous variables between participants with and without post-TPIAT steatosis.A total of 20 participants (mean: 13 ± 4 years; 12 female) were evaluated. Mean liver PDFF at research MRI was 7.4 ± 6.2% (range: 2-25%). Seven participants (35%) had categorical hepatic steatosis (PDFF5%) post-TPIAT, five of whom had pre-TPIAT steatosis, reflecting a 13% (2/15; 95% CI: 2-40%) incidence of post-TPIAT steatosis. Participant characteristics were not significantly different between subgroups with and without post-TPIAT steatosis. Mean PDFF at research MRI was not different between graft function subgroups (7.5% optimal/good vs. 7.3% marginal/failure; p = .96).Our study shows a moderate prevalence but low incidence of hepatic steatosis in a small sample of children and adolescents post-TPIAT. This study raises questions about a causal relationship between TPIAT and hepatic steatosis.

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

Studies systematically documenting US findings in children with acute pancreatitis are limited. Pancreas duct dilation is described as the most reliable finding of acute pancreatitis but this has not been rigorously examined in children.To systematically document US findings in children with acute pancreatitis and to define interobserver agreement on those findings.In this cross-sectional study we retrospectively reviewed images for all pediatric patientslt;18 years of age who had been prospectively enrolled in a registry of patients with index admissions for acute pancreatitis between March 2013 and July 2020. Two blinded observers (R1, R2) reviewed the first transabdominal US examination performed within 2 weeks of the pancreatitis attack for each patient.In 141 children, US was performed at a median of 1 day (interquartile range [IQR]: 0, 1) following acute attack. Thirty-three (23%, R1) and 38 (27%, R2) children had no abnormal findings on US. Peripancreatic edema was the most frequent finding documented by both reviewers (63% R1, 54% R2). The pancreatic duct was visible in only 35% of the children and was dilated in only 12% (R1) and 14% (R2). There was substantial to almost-perfect agreement between reviewers on findings of acute pancreatitis (κ=0.62-1), including duct visibility.Peripancreatic edema was the most frequently identified finding in children with acute pancreatitis, present in up to 63%, with almost perfect interobserver agreement. Duct dilation, cited in the literature as a reliable finding of acute pancreatitis, was rarely identified in our sample.

To compare the efficacy of magnetic resonance cholangiopancreatography (MRCP) with endoscopy retrograde cholangiopancreatography (ERCP) in children for the identification of pancreatic duct variants.We identified children with a pancreatic duct variant by ERCP and separately queried our MRCP database for similar variants. Patients with a paired ERCP-MRCP were reviewed. Three radiologists blinded to the ERCP and MRCP findings were asked to independently review the MRCP studies and define the pancreatic duct anatomy. These blinded reviewers also graded the magnetic resonance imaging examination quality.Seventy-four pairs of ERCP-MRCP examinations were identified. Pancreas divisum was the most frequent ductal variant encountered (73%). There was fair agreement between the radiology reviewers as to the quality of the magnetic resonance imaging studies (Fleiss Kappa agreement). Concordance of the reviewers with that of the ERCP was moderate for the exact diagnosis, moderate for the presence of pancreas divisum, and fair for agreement on the presence of any duct variant. Concordance among reviewers was moderate for the exact diagnosis, moderate for normal vs abnormal, and substantial for the presence of pancreas divisum.Diagnostic limitations exist when comparing MRCP with the gold reference standard of ERCP, specifically when assessing for pancreatic duct variants in children.

Background Acute pancreatitis (AP) is increasing in incidence in adult and pediatric patients. Identification of patients at high risk for progression to severe acute pancreatitis (SAP) is crucial, as it can lead to increased mortality and health system cost. Matrix metalloproteinases (MMPs) are endopeptidases which degrade extracellular matrix proteins and increase activity of pro-inflammatory cytokines. Tissue inhibitors of metalloproteinases (TIMPs) regulate MMP activity. Prior limited studies of MMPs and TIMPs have found some to be associated with development of SAP. The aim of this study was to further investigate the role of MMPs and TIMPs in detecting pediatric patients at risk for developing moderately severe AP or SAP. Methods Plasma samples were prospectively collected for patients Results Samples were collected from 7 subjects who developed SAP, 7 with moderately severe AP, 45 with mild AP and 44 healthy controls. MMP-9 (p = 0.04) and TIMP-1 (p = 0.01) levels were significantly higher in SAP patients. A multivariable logistic regression model using MMP-9 and TIMP-1 predicted SAP (AUROC 0.87, 95% CI 0.76–0.98). Conclusion We have demonstrated that MMP9 and TIMP1 levels are increased at AP presentation in pediatric patients who developed SAP during the course of illness. Further studies are needed to validate the use of MMPs and TIMPs as predictive tools for development of SAP in pediatric pancreatitis.

Objectives Pancreas divisum (PD) is a risk factor in children for the development of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (mPES) may be of clinical benefit, however, the clinical outcomes from endotherapy remain unclear. We sought to review the outcomes and safety of therapeutic ERCP in children with PD. Methods We performed a retrospective chart of children with PD who underwent an ERCP between February 2012 and December 2018. Pertinent patient, clinical and procedure information was collected including procedure-related adverse events. A follow-up questionnaire of the parent was conducted to determine the clinical impact from endotherapy. Results Fifty-eight ERCPs were performed in 27 patients (14 boys; mean age: 9.7 years, range 2-19) with PD. All patients underwent a successful mPES. A genetic variant was identified in 19/26 (73%) tested patients. Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58). Median follow-up interval from first ERCP intervention to questionnaire completion was 31.5 months (range: 4--72 months). Of the 20 questionnaire responders, 13 reported clinical improvement from endotherapy. Conclusions The majority of children from our PD cohort possessed at least 1 genetic variant. Most questionnaire responders had a favorable response to endotherapy. PEP rate was comparable with that of prior reports in adult patients.

With reports of ongoing duodenoscope contamination and pathogen transmission despite strict adherence to manufacturer reprocessing instructions, professional societies continue to release updated recommendations. Despite general guideline similarities, there are differences. Although adherence to guidelines does not entirely eliminate pathogen contamination or transmission, it is critical to strictly adhere to updated guidelines for maximum risk reduction. In the United States, the Food and Drug Administration and Centers for Disease Control and Prevention continue to offer updates regarding improved duodenoscope reprocessing techniques and endoscope design. This article critically analyzes currently available national and international duodenoscope reprocessing guidelines.

Background/objectives Drug induced acute pancreatitis (DIAP) as one of the acute pancreatitis (AP) risks factors is a poorly understood entity. The aim of the current study was to compare the characteristics and course of DIAP cases in children presenting with a first attack of AP. Methods Patients presenting with AP were included in a prospective database. We enrolled 165 AP patients that met criteria for inclusion. DIAP patients were included in that group if they were exposed to a drug known to be associated with AP and the rest were included in the non-drug induced-acute pancreatitis (non-DIAP) group. Results DIAP was observed in 40/165 (24%) of cases, 24 cases had drug-induced as the sole risk factor, and 16 had DIAP with another risk factor(s). The two groups were similar in intravenous fluid and feeding managements, but ERCP was more commonly performed in the non- DIAP group, 14 (11%), vs 0% in the DIAP group, p = 0.02. Moderately severe [9 (23%) vs 11 (9%)] and severe AP [7 (18%) vs 6 (5%)] were more commonly associated with DIAP than non- DIAP, p = 0.001. DIAP was more commonly associated with ICU stay, 10 (25%), vs 12 (10%), p = 0.01, hospital stay was longer in DIAP median (IQR) of 6 (3.9–11) days vs 3.3 (2–5.7) days in non- DIAP, p = 0.001. The DIAP group had a significantly higher proportion of comorbidities (p Conclusions DIAP is a leading risk factor for a first attack of AP in children and is associated with increased morbidity and severity of the pancreatitis course. DIAP warrants further investigation in future studies.

Introduction Pediatric chronic pancreatitis is increasingly diagnosed. Endoscopic methods [endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)] are useful tools to diagnose and manage chronic pancreatitis. Pediatric knowledge and use of these modalities is limited and warrants dissemination. Methods Literature review of publications relating to use of ERCP and EUS for diagnosis and/or management of chronic pancreatitis with special attention to studies involving 0--18 years old subjects was conducted with summaries generated. Recommendations were developed and voted upon by authors. Results Both EUS and ERCP can be used even in small children to assist in diagnosis of chronic pancreatitis in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15 kg for EUS and 10 kg for ERCP can be technically challenging. These procedures should be done optimally by appropriately trained endoscopists and adult gastroenterology providers with appropriate experience treating children. EUS and ERCP-related risks both include perforation, bleeding and pancreatitis. EUS is the preferred diagnostic modality over ERCP because of lower complication rates overall. Both modalities can be used for management of chronic pancreatitis -related fluid collections. ERCP has successfully been used to manage pancreatic duct stones. Conclusion EUS and ERCP can be safely used to diagnose chronic pancreatitis in pediatric patients and assist in management of chronic pancreatitis-related complications. Procedure-related risks are similar to those seen in adults, with EUS having a safer risk profile overall. The recent increase in pediatric-trained specialists will improve access of these modalities for children.

OBJECTIVES To utilize a Luminex platform to examine multiple cytokines simultaneously as well as clinical laboratory testing to identify markers that predict acute pancreatitis severity in the pediatric population on admission. STUDY DESIGN Patients (

Objective The natural course of patients who develop acute pancreatitis (AP) can range from mild to severe acute pancreatitis (SAP). The aim of this study was to evaluate for early predictors of developing SAP during the first episode of AP in a prospective pediatric cohort. Methods Clinical data were prospectively collected and subsequently analyzed for pediatric patients presenting with their first episode of AP between March 2013 and January 2017 to Cincinnati Children's Hospital Medical Center. Results A total of 118 patients were included in the analysis, and 22 (18.6%) developed SAP. Patients who developed SAP had significantly higher values of blood urea nitrogen (BUN) (P = 0.007), magnesium (P = 0.04), glucose (P = 0.03), sodium (P = 0.03), and C-reactive protein (P = 0.02). A logistic regression model with BUN as a predictor of SAP was superior to any other combination of variables (area under the receiver operating characteristic curve, 0.75; 95% confidence interval, 0.61-0.89; sensitivity, 63%; specificity, 81%; positive predictive value, 43%; negative predictive value, 91%). Conclusions This study generated a predictive model using elevated BUN as a significant predictor of SAP. The findings are useful for early identification of pediatric patients at higher risk of developing SAP.

To determine the diagnostic sensitivity of serum biomarkers and imaging in the diagnosis of acute pancreatitis in children.This was a cross-sectional analysis of prospective registry data for children (age21 years) whose first documented attack of acute pancreatitis occurred between March 2013 and October 2016 at a single-institution, tertiary care center. Main outcome was sensitivity of serum biomarkers and of imaging modalities, measured via descriptive statistics.In total, 112 children met the criteria for acute pancreatitis; 57 (51%) were male with a median age of 13.4 years (IQR 9.3-15.8 years). Serum amylase and lipase levels were obtained in 85 (76%) and 112 (100%) patients, respectively. Imaging was performed in 98 (88%) patients, with abdominal ultrasound (US) performed in 84 (75%) and computed tomography and/or magnetic resonance imaging performed in 46 (41%) patients. Fifty-three (47%) patients met all 3 diagnostic criteria (clinical, biochemical, and imaging) for acute pancreatitis. Laboratory testing had a 5.4% false-negative rate for acute pancreatitis. Serum lipase alone and amylase alone were 95% (95% CI 89%-98%) and 39% (95% CI 28%-50%) sensitive for acute pancreatitis, respectively. Imaging (any modality) was 61% sensitive (95% CI 51%-71%) for acute pancreatitis with a 34% false-negative rate. US alone was 52% (95% CI 41%-63%) sensitive for acute pancreatitis and computed tomography/magnetic resonance imaging was 78% (95% CI 63%-89%) sensitive. Combinations of diagnostic criteria performed no better than laboratory testing alone.The majority of children coming to medical attention with their first documented occurrence of acute pancreatitis have characteristic symptoms. Serum lipase is highly sensitive for the diagnosis of acute pancreatitis, and serum amylase is moderately sensitive. Imaging, particularly US, is only moderately sensitive, and cross-sectional imaging provides greater sensitivity for diagnosing acute pancreatitis.

The aims of the study were to describe infliximab adherence in a pediatric inflammatory bowel disease cohort, to identify demographic and disease factors associated with adherence, and to examine differences in acute care use among adherent and nonadherent patients. Charts of patients who received infliximab at the Children's Hospital of Wisconsin (CHW) between October 2010 and October 2012 were retrospectively reviewed. A total of 151 patients met the inclusion criteria; 91.4% of the patients were adherent. Nonadherent patients had more emergency room visits and hospitalizations than adherent patients. The study is the first to show high adherence rates to infliximab in a pediatric cohort.

among other lay presentations.It is commonly assumed that this is a small town or ruralissue.Ourhypothesis,however,isthatthisisamuchmorewidely distributed problem that affects all of mid-Americabetween the Allegheny and the Rocky Mountains, and insomepartsofbothcoasts.Arapidlyburgeoningamountofliterature, which is referenced in this article, and describesthis “surgeon shortage,” has been developing in both layand professional texts. This shortage has been difficult toquantifynationallyandlocally;consensusfiguresshowthat7.68 general surgeons per 100,000 population in 1981dropped to 5.69 in 2005. Interestingly, in the same timeperiod, the urban surgeon ratio fell 27%, and the ruralsurgeon ratio fell 21%.

Pain from chronic pancreatitis leads to disability, malnutrition, and narcotic dependence. This study demonstrates the efficacy of bilateral thoracoscopic splanchnicectomy in reducing pain associated with chronic pancreatitis. This study reviews results from this procedure between 1998 and 2006. Data included pain levels, hospital admissions, nutritional status, and the duration between splanchnicectomy and pancreatic resection. Narcotic use was determined from the Kentucky All Schedule Prescription Electronic Reporting system. Fifty-four patients underwent splanchnicectomy with technical success in 98 per cent and immediate symptom relief in 43 per cent. Additional surgery occurred in 44 per cent (average time to surgery was 26 months). Failure of pain relief occurred in 17 per cent, early recurrence (6–12 months) occurred in 15 per cent, and 68 per cent had over a year of relief. Admissions decreased from 5.8 to 2.9 post surgery. Average pain levels decreased from 8.7 to 6.1 post surgery ( P < 0.001). Kentucky All Schedule Prescription Electronic Reporting demonstrated decreased or stable narcotic use in half of the patients. Over half (55%) maintained or gained weight, whereas 39 per cent experienced weight loss. Discharge occurred 24-hours after surgery. Bilateral thoracoscopic splanchnicectomy demonstrates a positive impact on pain control, hospital admissions, nutritional status, and narcotic use. Thoracoscopic splanchnicectomy is an effective and safe option in the treatment of pain from chronic pancreatitis.

Background Review of 1.6 million cholecystectomies, from 1992 to 1999, demonstrated a 0.5% incidence of bile duct injury, despite increasing experience with laparoscopy. The incidence has not decreased after the "learning curve." The management of major bile duct injuries has traditionally been by hepaticojejunostomy. Endoscopy has been increasingly used to treat these injuries. This study reviews the senior author's endoscopic treatment of bile duct injuries. Study Design This is a retrospective study, from 1991 to 2006, examining data on 292 patients who were referred for postcholecystectomy problems; 199 had cholecystectomy-related injuries and 93 had other pathologies. Sixty-seven patients had bile duct injuries (Amsterdam Academic Medical Center Classification, types B, C, and D). Nineteen patients underwent bilioenteric bypass for complete bile duct occlusion or transection. In the remaining 48, endoscopic retrograde cholangiopancreatography (ERCP) evaluation and treatment were possible. Our protocol called for biliary stenting for 11 to 14 months, with stent changes at 3-month intervals. Short- and longterm results were evaluated by clinical, radiologic, and laboratory studies. Results Forty-six patients were selected for endoscopic management by balloon dilation and biliary stent placement. The mean ± SD duration of endoscopic stenting was 12±9.8 months and followup was 30±24 months after stent removal. During the followup period, 10 of 46 patients (22%) had recurrent stricture: 6 (13%) responded to endoscopic biliary stenting and 4 (9%) required hepaticojejunostomy. Complications included pancreatitis (8%). There were no deaths in the endoscopic group. Conclusions ERCP intervention is a safe, effective, minimally invasive treatment for bile duct strictures after cholecystectomy and can be an alternative to hepaticojejunostomy.

Pancreas divisum is the most common anatomic variant of pancreatic development and may lead to pancreatitis. This study evaluated the efficacy of endoscopic stenting in patients with chronic pancreatitis due to pancreas divisum.Between 1993 and 2005, 32 patients with chronic pancreatitis due to pancreas divisum were treated with endoscopic stenting. Each patient underwent an endoscopic retrograde cholangiopancreatography to confirm the diagnosis of pancreas divisum prior to endoscopic stenting. A survey was conducted by telephone conversation to evaluate pain intensity, symptom relief, hospital admissions, quality of life and pain medication usage, which was verified by a statewide narcotic electronic database. Eight of the 32 patients were unavailable for the interview and were not included in the analysis of the study. Results are expressed as mean +/- standard error of the mean (SEM).Twenty-four patients were followed up for a period of 59.6 months. The overall pain level average in the 24 patients decreased significantly from 8.9 +/- 0.4 pre-stenting to 3.9 +/- 0.7 post-stenting (P0.05) on a scale of 1 to 10. The number of hospital admissions per year in these patients decreased significantly from 7.3 +/- 2.1 pre-stenting to 2.1 +/- 0.4 post-stenting (P0.05). Pain medication usage reported by the patients found a decrease in 58% of patients, 21% remained the same, and 13% increased their usage. There was improvement in nausea (67%), vomiting (63%), and chronic pain (75%). Thirteen patients (55%) were treated endoscopically without requiring surgery and 11 (45%) patients required surgery after stenting. These 11 patients had surgery an average of 25 months post-stenting. The complication rate of post-procedural pancreatitis was 3.4%. No mortality was reported in this study.Endoscopic stenting of the pancreatic duct is a safe and effective first treatment for patients with pancreatitis secondary to pancreas divisum. Surgery, when performed for endoscopic stenting failure, is effective as an adjunctive treatment.

Although the protective effects of fever have been recognized for many decades now, evidence regarding the converse detrimental effects of hypothermia in surgical patients remains relatively novel and continues to emerge.1–3 Intraoperative hypothermia, which is thought to occur in as many as 20% of surgical patients today, results from direct heat loss in a cool operating suite environment and impaired thermoregulation associated with anesthesia.3 Hypothermia has been reported to result in delayed wound healing; increased surgical site infection,4 prolonged length of hospitalization,4 increased myocardial complications, 5 increased intraoperative blood loss and need for transfusion, which, in turn, worsens hypothermia,6,7 delayed recovery from anesthesia,8 negative catabolism and nitrogen balance,9 increased postoperative discomfort,10 and an overall higher mortality.6,11 Consequently, perioperative temperature monitoring and avoidance of intraoperative hypothermia are now being recognized as worthy quality improvement measures aimed at optimizing surgical care, along with somewhat more broadly defined measures such as timely antibiotic administration,12 venous thromboembolism prophylaxis,13 and strict glycemic control.13,14 However, despite general acceptance among the surgical community, the mechanisms by which hypothermia exerts its detrimental effects, particularly in the development of infectious sequelae, are not well elucidated. It has been proposed that hypothermia may predispose to local wound and systemic infection in at least 2 ways. Firstly, hypothermia evokes a thermoregulatory vasoconstriction in skin and subcutaneous vessels to minimize heat loss. In doing so, oxygen delivery, and, therefore, oxygen wound tensions are reduced. The subsequent wound hypoxia has been directly correlated with infective wound events.15–17 Secondly, hypothermia has been shown to inhibit T-cell-mediated antibody production and nonspecific neutrophil oxidative killing.18–20 Innate immune mechanisms, such as neutrophil oxidative killing, play a key role in preventing infection after exposure to an intraoperative bacterial challenge. A decisive period within a very few hours exists, when inevitable contamination may transform into local or general infection if innate immune defense mechanisms fail to prevail over pathogenic contaminants.21,22 Consequently, the continuing development of infection among surgical patients, despite appropriate antibiotic use and combined with emerging drug resistance, has led to further focus upon optimizing innate immune mechanisms to minimize infection rate. In this report, we provide further insight into the immunologic mechanisms underlying hypothermic injury in surgery. Specifically, we investigate 2 key parameters of innate defense mechanisms at varying physiologic temperatures; namely, monocyte antigen presentation via major histocompatibility class II (HLA-DR) surface receptor expression, and cytokine production. Although we describe our findings in the context of surgery, we believe these concepts may be extrapolated to include other entities in medicine, such as pre-transplant organ-preservation, deliberate hypothermic circulatory arrest, and burns and trauma.

General surgeons commonly perform upper gastrointestinal endoscopy in practice, but few perform endoscopic retrograde cholangiopancreatography (ERCP), partly because of limited training opportunities. This report focuses on the value of an ERCP fellowship training program to a broad-based, mature residency in surgery and our observations on the experience required for surgeons to be trained in advanced interventional ERCP. Since the program was initiated in 1992, 13 ERCP fellows have been trained for individual periods of 6 to 14 months. This study investigated all procedures with fellow involvement (2,008 cases) from among a total experience of 3,641 ERCPs. Data collected included type of ERCP (diagnostic/therapeutic), fellow success in cannulating the duct of interest, and faculty success in cases of fellows who failed. Of the 13 fellows, 9 had previous endoscopy experience, but none had training in ERCP. An 85% cannulation rate was accepted as successful, and cannulation rates for each fellow were calculated for each 3-month period. The 85% mark was reached by 4 (31%) of 13 fellows in the first period, 2 of 13 fellows (15%) in the second period, 5 of 11 fellows (45%) in the third period, 7 of 10 fellows (70%) in the fourth period, and 1 of 1 fellow (100%) in the fifth period of training. On the average, it took 7.1 months and 102 ERCPs for trainees to reach desired success levels. Success came more promptly with prior exposure to endoscopy. Fellows without prior endoscopic experience required 148 cases to reach 85% success. Resident surgical experience with major pancreatic resections increased threefold after establishment of the fellowship. Training in ERCP is possible within the scope of a surgical fellowship in a reasonable length of time and experience. Complication rates remain low even with fellow involvement. Establishment of an ERCP program increases the focus and experience of pancreas surgery in a surgical residency for chief residents.