Post-ERCP adverse events in children: a systematic review and meta-analysis of post-ERCP pancreatitis incidence with synthesis of risk factors and prevention strategies.

backgroundEndoscopic retrograde cholangiopancreatography (ERCP) is increasingly used in children with pancreatobiliary disease, but pediatric adverse-event estimates remain variable. We updated the evidence on post-ERCP adverse events in children, pooled post-ERCP pancreatitis (PEP) incidence when study-level data allowed, and summarized reported risk factors and prevention strategies.

methodsWe conducted a systematic review and meta-analysis of English-language literature published from January 2015 to June 2025 in PubMed, Embase, Web of Science, and the Cochrane Library. Eligible quantitative analyses included non-overlapping pediatric primary studies reporting extractable numerators and denominators for post-ERCP adverse events. Prior systematic reviews and meta-analyses were used for background comparison and reference checking only. Random-effects meta-analysis of proportions was planned for outcomes with at least three eligible studies. Risk-factor and prevention data were summarized narratively when definitions or adjustment strategies were too heterogeneous for pooling.

resultsSixty-five sources were included in the qualitative synthesis, and 15 non-overlapping primary studies contributed extractable PEP numerators and denominators for quantitative synthesis. PEP was the most frequent adverse event, with a pooled incidence of approximately 7.3% (95% CI, 5.1% to 10.4%; I-squared = 83.7%). Study-level PEP percentages, denominator units, and available adverse-event definition or reporting notes are now shown in Table 1. Bleeding was uncommon and perforation was rare but clinically important. Recurrent or chronic pancreatitis, pancreatic duct manipulation, pancreatic contrast injection, sphincterotomy, difficult cannulation, younger age, lower procedural volume, and trainee involvement or operator experience were recurring risk domains, although not all studies reported stratified event counts. Pediatric evidence for NSAIDs and prophylactic pancreatic stenting remains limited compared with adult data, and both strategies require child-specific dosing, equipment selection, and contraindication assessment.

conclusionsPediatric ERCP carries measurable adverse-event risk, particularly PEP. The pooled estimate provides a current benchmark, but heterogeneity and inconsistent reporting limit certainty. Standardized pediatric definitions, non-overlapping reporting, and prospective multicenter datasets are needed.

trial registrationPROSPERO CRD420251084264.