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Implementation of a risk-stratified perioperative safety pathway for children undergoing elective ERCP: a
Tian-Hang Wu1, Yun-Xia Zhang1, Shi-Qin Qi1
1Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, Anhui, China.
Background:
Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly used in children with pancreaticobiliary diseases. Although pediatric ERCP is feasible in experienced centers, perioperative adverse events, delayed recognition of early warning signs, and drainage-related problems remain important safety concerns. This study evaluated the real-world implementation of a risk-stratified perioperative safety pathway in children undergoing elective ERCP.
Methods:
This single-center retrospective historical cohort study included consecutive children who underwent elective ERCP at Anhui Provincial Children's Hospital between June 2022 and December 2025. Children treated from June 2022 to June 2023 received routine perioperative management, whereas those treated from July 2023 to December 2025 were managed under a risk-stratified perioperative safety pathway. The pathway incorporated structured preoperative risk assessment, procedure-related handover, early warning-based postoperative monitoring, standardized nasobiliary drainage management, and family-centered perioperative education. The primary outcome was the proportion of children who experienced at least one prespecified in-hospital perioperative adverse event. Secondary outcomes included postoperative recovery indicators and caregiver-reported care experience.
Results:
A total of 63 children were included, with 30 in the routine management group and 33 in the risk-stratified pathway group. Baseline demographic and disease characteristics were comparable between groups. Compared with routine management, the pathway group had a shorter time to first flatus (20.3 ± 5.1 vs. 27.5 ± 6.2 h, P < 0.01), earlier resumption of oral intake (33.6 ± 7.9 vs. 44.2 ± 8.7 h, P < 0.01), and a shorter length of hospital stay (5.2 ± 1.8 vs. 7.5 ± 2.1 days, P < 0.01). The proportion of children with at least one in-hospital perioperative adverse event was lower in the pathway group than in the routine management group (24.2% vs. 53.3%, P = 0.017). Nasobiliary drainage-related complications were less frequently observed in the pathway group (6.1% vs. 23.3%, P = 0.046).
Conclusions:
In this single-center retrospective historical cohort, implementation of a risk-stratified perioperative safety pathway was associated with faster postoperative recovery, fewer in-hospital perioperative adverse events, and better caregiver-reported care experience. Exploratory findings for individual adverse-event components, including nasobiliary drainage-related complications, should be interpreted cautiously because of the small sample size, multiple comparisons, and potential temporal confounding. Prospective multicenter studies are needed to validate these associations.
