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The latest information about the 2019 Novel Coronavirus, including vaccine clinics for children ages 5 years old and older.

La información más reciente sobre el nuevo Coronavirus de 2019, incluidas las clínicas de vacunación para niños de 5 años en adelante.

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Roberto Gugig, MD

  • “Its very satisfying to be able to avoid a surgery for a child.”

I am a pediatric gastroenterologist that specializes in performing advanced endoscopic procedures. Endoscopy has gone from a purely diagnostic tool to one that allows us to perform treatment directly. Procedures can now sometimes be performed using a less invasive endoscopic approach. Being able to treat a child without an operation is a big deal. Everyone prefers a less invasive procedure.

Specialties

Gastroenterology

Work and Education

Professional Education

Universidad Central de Venezuela, Caracas, Miranda, 6/1/1994

Internship

UCLA David Geffen School Of Medicine Registrar, Los Angeles, CA, 6/1/1996

Residency

Maimonides Medical Center, Brooklyn, NY, 6/1/1997

Miami Children's Hospital, Miami, FL, 6/1/1999

Fellowship

UCSF Graduate Division - Fellowships, *San Francisco, CA, 6/1/2002

Board Certifications

Pediatric Gastroenterology, American Board of Pediatrics

All Publications

Landscape of Pediatric Endoscopic Ultrasound in a United States Tertiary Care Medical Center. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Cagil, Y., Gugig, R. 2022

Abstract

Endoscopic ultrasound (EUS) is a commonly used radiation-sparing procedure in adult patients for diagnostic sampling of gastrointestinal lesions and fluid collections, gastric variceal hemostasis, biliary/pancreatic duct drainage, and endo-surgical interventions. Integration of EUS in pediatrics is still in its infancy with limited data regarding its use. The present study analyzes utilization, diagnostic and therapeutic roles of pediatric EUS and evolution in these parameters over time.Records of patients 18years or younger from 2009 to 2020 at our tertiary pediatric care center were retrospectively identified. Patient demographics, symptoms, laboratory studies, EUS indications and interventions, and clinical outcomes of the procedures were analyzed. Statistical analysis was performed using Student's T-test, Pearson chi-square and Fisher's exact tests.306 EUS procedures were performed during the study period, for 279 pediatric patients. These included 287 (93.8%) upper EUS and 19 (6.2%) lower EUS. 229 procedures were diagnostic (74.8%) and 77 were therapeutic (25.2%). EUS indications included evaluation and therapy of the pancreaticobiliary region (231, 75.5%), subepithelial or regional lesion (54, 17.8%), celiac plexus block (19, 6.2%) and hemostasis (14, 4.5%). Diagnostic sampling was performed in 52 of these EUS procedures, with a 96.2% diagnostic yield. 98.7% of therapeutic procedures were technically successful and there were no associated adverse events.The diagnostic and therapeutic role for EUS in adults has expanded dramatically, however the role of EUS in pediatrics is not well-defined. In this, the largest pediatric EUS study to date, our data support the safety and utility of diagnostic and therapeutic EUS in pediatrics.

View details for DOI 10.1097/MPG.0000000000003403

View details for PubMedID 35149652

Predictors of Prolonged Fluoroscopy Exposure in Pediatric ERCP: Results from the Large PEDI Multicenter Cohort. Journal of pediatric gastroenterology and nutrition Liu, Q. Y., Ruan, W., Fishman, D. S., Barth, B. A., Tsai, C. M., Giefer, M., Kim, K. M., Martinez, M., Dall'oglio, L., De Angelis, P., Torroni, F., Faraci, S., Bitton, S., Wilsey, M., Khalaf, R. T., Werlin, S., Dua, K., Huang, C., Gugig, R., Mamula, P., Fox, V. L., Grover, A., Quiros, J. A., Zheng, Y., Troendle, D. M. 2021

Abstract

BACKGROUND AND AIMS: Ionizing radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) is an important quality issue especially in children. We aim to identify factors associated with extended fluoroscopy time (FT) in children undergoing ERCP.METHODS: ERCP on children 18years from 15 centers were entered prospectively into a REDCap database from 5/2014 until 5/2018. Data were retrospectively evaluated for outcome and quality measures. A univariate and step-wise linear regression analysis was performed to identify factors associated with increased FT.RESULTS: 1073 ERCPs performed in 816 unique patients met inclusion criteria. Median age was 12.2years (IQR 9.3-15.8). 767 (71%) patients had native papillae. The median FT was 120seconds (IQR 60-240). Factors associated with increased FT included procedures performed on patients with chronic pancreatitis, ERCPs with ASGE difficulty grade 3, ERCPs performed by Pediatric Gastroenterologist (GI) with Adult GI supervision, and ERCPs performed at non-free standing children's hospitals. Hispanic ethnicity was the only factor associated with lower FT.CONCLUSION: Several factors were associated with prolonged FTs in pediatric ERCP that differed from adult studies. This underscores that adult quality indicators cannot always be translated to pediatric patients. This data can better identify children with higher risk for radiation exposure and improve quality outcomes during pediatric ERCP.An infographic is available for this article at:http://links.lww.com/MPG/C570.

View details for DOI 10.1097/MPG.0000000000003347

View details for PubMedID 34724445

Applicability, efficacy, and safety of over-the-scope clips in children. Gastrointestinal endoscopy Sharma, S., Barakat, M., Urs, A., Campbell, D., Rao, P., Schluckebier, D., Gugig, R., Thomson, M. 2021

Abstract

Over-the-scope clips (OTSCs) are now becoming popular in endoscopy performed in adults for indications such as acute nonvariceal GI bleeding, anastomotic bleeding, and for closure of gastrocutaneous and postgastrostomy fistulae. Varied sizes of clip are available, but even the smallest, 8.5 to 9.8mm in diameter with its loading device on the tip of the endoscope, increases device and endoscope intubation diameters up to 14.65mm. This may present challenges in terms of the size of the patient in whom it might be used. OTSCs appear to be effective and safe in the hands of those who are trained appropriately in endoscopy on adult patients; however, the experience of OTSC application in children is not reported. Here we present results of a service evaluation of this technology at 2 regional/national referral pediatric endoscopy units in the United Kingdom and the United States.Two tertiary centers' databases were searched to identify cases in which OTSCs were used. Demographics, presentation, anthropometry, comorbidities, efficacy, adverse events, and postprocedure follow-up were recorded, with identification of resolution or recurrence.OTSC procedures were performed on 24 occasions in 20 patients (11 girls) between February 2018 and February 2021. Patients had a mean age of 12 years (range, 5-17) and a mean weight of 44.42 kg (range, 18.2-70.3). Indications were nonhealing PEG site fistulae (n= 7), acute nonvariceal upper GI bleeding (ANUGIB) from gastric ulcers (5), ANUGIB from duodenal ulcers (3), nonhealing bleeding anastomotic ulcer (3), esophageal mucocutaneous fistula (1), and gastric perforation (1). Technical success was achieved in all but 1 case (95%), and clinical success was achieved in 18 cases (90%).The OTSC device appears to be effective in children (minimum age 5 years and minimum weight 18 kg) in a limited number of situations including anastomotic ulcer, closure of leaking PEG site, gastric perforation, and bleeding peptic ulcers. The operator should be an experienced endotherapeutic endoscopist with specific OTSC training, and the type and size of the OTSC device should be carefully considered, along with any comorbidities of the patient that may preclude success and/or lead to potential adverse events such as esophageal perforation.

View details for DOI 10.1016/j.gie.2021.10.011

View details for PubMedID 34662583

Nationwide evolution of Pediatric ERCP Indications, Utilization and Re-Admissions over Time. The Journal of pediatrics Barakat, M. T., Cholankeril, G., Gugig, R., Berquist, W. E. 2020

Abstract

OBJECTIVES: We conducted the present all-capture US population level study of pediatric Endoscopic retrograde cholangiopancreatography (ERCP) P to analyze outcome and utilization trends over time.STUDY DESIGN: Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric hospitalizations (age <20 years) where ERCP was performed and assessed ERCP-associated readmissions. ICD-9-CM codes were used to identify hospitalization diagnosis, co-morbidities and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P < 0.05) of 30-day readmission.RESULTS: 11,060 hospitalized pediatric patients underwent ERCP from 2005-2014. Most were female (n=8859, 81%), 14-20 years of age (n=9342, 84%), and White (n=4230, 45%). 85% of ERCPs were therapeutic and leading indications were biliary (n=5350, 48%) and pancreatitis (n=3218, 29%). 13% of patients were re-admitted post-ERCP. Odds for 30-day re-admission were highest for patients with a history of liver transplant, ages between 0-4 years, male sex, and obesity (P < .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than rural hospitals for prolonged length of stay associated with ERCP.CONCLUSIONS: These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights regarding trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics and patient comorbidities associated with pediatric post-ERCP outcomes including re-admission and length of stay.

View details for DOI 10.1016/j.jpeds.2020.11.019

View details for PubMedID 33197494

Return to Native Drainage: Duodenal Biliary Fistula Formation Following Pediatric Hepatobiliary Surgery with Roux-en-Y Reconstruction. Digestive diseases and sciences Barakat, M. T., Josephs, S., Gugig, R. 2020

View details for DOI 10.1007/s10620-020-06372-6

View details for PubMedID 32533541

ENDOSCOPIC ULTRASOUND-GUIDED COIL PLACEMENT IS AN EFFECTIVE, SAFE AND RADIATION-SPARING APPROACH FOR MANAGEMENT OF GASTRIC VARICEAL BLEEDING IN CHILDREN AND ADOLESCENTS Barakat, M., Gugig, R. MOSBY-ELSEVIER. 2020: AB53
THE MAJORITY OF CHILDREN AND ADOLESCENTS WITH PANCREAS DIVISUM AND ACUTE RECURRENT PANCREATITIS EXPERIENCE CLINICAL IMPROVEMENT AFTER ERCP WITH MINOR PAPILLOTOMY Barakat, M., Husain, S. Z., Gugig, R. MOSBY-ELSEVIER. 2020: AB500
The Roles of EUS and ERCP in the Evaluation and Treatment of Chronic Pancreatitis in Children: A Position Paper from the NASPGHAN Pancreas Committee. Journal of pediatric gastroenterology and nutrition Liu, Q. Y., Gugig, R., Troendle, D. M., Bitton, S., Patel, N., Vitale, D. S., Abu-El-Haija, M., Husain, S. Z., Morinville, V. D. 2020

Abstract

INTRODUCTION: Pediatric chronic pancreatitis (CP) is increasingly diagnosed. Endoscopic methods (endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)) are useful tools to diagnose and manage CP. 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 CP 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 CP in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15kg for EUS and 10kg 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 due to lower complication rates overall. Both modalities can be used for management of CP-related fluid collections. ERCP has successfully been used to manage pancreatic duct stones.CONCLUSIONS: EUS and ERCP can be safely used to diagnose CP in pediatric patients and assist in management of CP-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.

View details for DOI 10.1097/MPG.0000000000002664

View details for PubMedID 32079975

Initial Experience with EUS-guided Coil Placement for Pediatric Gastric Variceal Hemostasis. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Foley, M. A., Gugig, R. n. 2020; Publish Ahead of Print

Abstract

Gastric variceal (GV) bleeding is among the most morbid sequelae of portal hypertension, with mortality ranging from 30-50%. Pediatric data focused on endoscopic approaches to management are needed. The present study represents the first pediatric case series of endoscopic ultrasound (EUS)-guided coil placement within feeding vessels as monotherapy for management of GV bleeding.Using our prospectively-maintained endoscopy database, we identified patients 18years and younger who underwent EUS-guided coil placement for management of GV bleeding from 2008-2018. Demographics, indication, procedural interventions/findings, and available clinical outcomes data were analyzed.12 patients (median age 15, range 11-18years) underwent EUS-guided coil placement for GV bleeding. All had portal hypertension, with EV in 58.3% and prior GV bleeding with attempted endoscopic management in 75%. Coil placement was accomplished using a linear echoendoscope and a 19-gauge needle. A mean of 2.75 ( 0.43) coils were placed in each patient (4, 6, 8, and 10mm Nester Embolization Coils, Cook Medical). Immediate hemostasis was achieved in all patients, and 25% of patients developed recurrent gastric varices at a median of 5.5months following the initial EUS-guided coil placement (range 4-6months) over the median 12month follow-up period.The present study establishes the feasibility and efficacy of EUS-guided coil placement as monotherapy for GV bleeding in children and adolescents. The technique was technically successful, with primary hemostasis achieved in all patients. EUS-guided embolization with coils may represent an alternative to current approaches for management of highly morbid GV bleeding.

View details for DOI 10.1097/MPG.0000000000003028

View details for PubMedID 33394889

The Roles of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography in the Evaluation and Treatment of Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. Journal of pediatric gastroenterology and nutrition Liu, Q. Y., Gugig, R. n., Troendle, D. M., Bitton, S. n., Patel, N. n., Vitale, D. S., Abu-El-Haija, M. n., Husain, S. Z., Morinville, V. D. 2020; 70 (5): 68193

Abstract

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.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.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 15kg for EUS and 10kg 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.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.

View details for DOI 10.1097/MPG.0000000000002664

View details for PubMedID 32332479

Fluoroscopy Time during ERCP performed for Children and Adolescents is Significantly Higher with Low-volume Endoscopists. Journal of pediatric gastroenterology and nutrition Barakat, M. T., Gugig, R. n., Imperial, J. n., Berquist, W. E. 2020

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults, however the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP.We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002-2017 using our institution's paper and electronic medical record system along with a prospectively-maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume >100 and low volume endoscopists (LVE) as <100 (pediatric + adult) ERCPs/year.385 ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas) and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times varied dramatically between procedures and providers. Median fluoroscopy time was 4.85(+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of fluoroscopy time (p<0.001). In addition to endoscopist volume, procedure-specific predictors of increased fluoroscopy time included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age<4 years or >16 years at the time of ERCP (p<0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with fluoroscopy time.Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower fluoroscopy time relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted fluoroscopy time for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.

View details for DOI 10.1097/MPG.0000000000002914

View details for PubMedID 32833892

Out-of-pocket Cost Burden in Pediatric Inflammatory Bowel Disease: A Cross-sectional Cohort Analysis INFLAMMATORY BOWEL DISEASES Sin, A. T., Damman, J. L., Ziring, D. A., Gleghorn, E. E., Garcia-Careaga, M. G., Gugig, R. R., Hunter, A. K., Burgis, J. C., Bass, D. M., Park, K. T. 2015; 21 (6): 1368-1377

Abstract

Pediatric inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), can result in significant morbidity requiring frequent health care utilization. Although it is known that the overall financial impact of pediatric IBD is significant, the direct out-of-pocket (OOP) cost burden on the parents of children with IBD has not been explored. We hypothesized that affected children with a more relapsing disease course and families in lower income strata, ineligible for need-based assistance programs, disparately absorb ongoing financial stress.We completed a cross-sectional analysis among parents of children with IBD residing in California using an online HIPAA-secure Qualtrics survey. Multicenter recruitment occurred between December 4, 2013 and September 18, 2014 at the point-of-care from site investigators, informational flyers distributed at regional CCFA conferences, and social media campaigns equally targeting Northern, Central, and Southern California. IBD-, patient-, and family-specific information were collected from the parents of pediatric patients with IBD patients younger than 18 years of age at time of study, carry a confirmed diagnosis of CD or UC, reside in and receive pediatric gastroenterology care in California, and do not have other chronic diseases requiring ongoing medical care.We collected 150 unique surveys from parents of children with IBD (67 CD; 83 UC). The median patient age was 14 years for both CD and UC, with an overall 3.7 years (SD 2.8 yr) difference between survey completion and time of IBD diagnosis. Annually, 63.6%, 28.6%, and 5.3% of families had an OOP cost burden >$500, >$1000, and >5000, respectively. Approximately one-third (36.0%) of patients had emergency department (ED) visits over the past year, with 59.2% of these patients spending >$500 on emergency department copays, including 11.1% who spent >$5000. Although 43.3% contributed <$500 on procedure and test costs, 20.0% spent >$2000 in the past year. Families with household income between $50,000 and $100,000 had a statistically significant probability (80.6%) of higher annual OOP costs than families with lower income <$50,000 (20.0%; P < 0.0001) or higher income >$100,000 (64.6%; P < 0.05). Multivariate analysis revealed that clinical variables associated with uncontrolled IBD states correlated to higher OOP cost burden. Annual OOP costs were more likely to be >$500 among patients who had increased spending on procedures and tests (odds ratio [OR], 5.63; 95% confidence interval [CI], 2.73-11.63), prednisone course required over the past year (OR, 3.19; 95% CI, 1.02-9.92), at least 1 emergency department visit for IBD symptoms (OR, 2.84; 95% CI, 1.33-6.06), at least 4 or more outpatient primary medical doctor visits for IBD symptoms (OR, 2.82; 95% CI, 1.40-5.68), and history of 4 or more lifetime hospitalizations for acute IBD care (OR, 2.60; 95% CI, 1.13-5.96).Previously undocumented, a high proportion of pediatric IBD families incur substantial OOP cost burden. Patients who are frequently in relapsing and uncontrolled IBD states require more acute care services and sustain higher OOP cost burden. Lower middle income parents of children with IBD ineligible for need-based assistance may be particularly at risk for financial stress from OOP costs related to ongoing medical care.

View details for DOI 10.1097/MIB.0000000000000374

View details for Web of Science ID 000355315800020

View details for PubMedID 25839776