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Updated: Nov 18, 2025
Laparoscopic Choledochal Cyst Excision and Roux-en-Y Choledochojejunostomy in Adults
Published on: February 28, 2025
A prospective multicenter analysis from the Pediatric ERCP Database Initiative: predictors of choledocholithiasis at
Douglas S Fishman1, Brad Barth2, Cynthia Man-Wai Tsai1
1Section of Pediatric Gastroenterology, Hepatology and Nutrition; Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
Insights
Evaluating adult criteria for pediatric choledocholithiasis shows low sensitivity. Conjugated bilirubin levels significantly improve stone detection in children, suggesting a need for pediatric-specific guidelines.
Area of Science:
- Pediatric Gastroenterology
- Endoscopic Retrograde Cholangiopancreatography (ERCP)
Background:
- Management of suspected choledocholithiasis in children presents challenges.
- Existing adult guidelines for choledocholithiasis evaluation lack proven efficacy in pediatric patients.
Purpose of the Study:
- To assess the applicability of adult-based criteria for diagnosing choledocholithiasis in pediatric patients.
- To determine if conjugated bilirubin levels enhance the detection of choledocholithiasis in children.
Main Methods:
- A prospective multicenter study involving pediatric patients (<19 years) undergoing ERCP for suspected choledocholithiasis.
- Analysis included adult guidelines, abdominal ultrasound, and laboratory indices, focusing on total and conjugated bilirubin.
Main Results:
- Adult guidelines demonstrated low sensitivity (20%-69%) and variable specificity (27%-91%) in pediatric patients.
- Transabdominal ultrasound showed no significant difference between groups.
- Both total and conjugated bilirubin levels, particularly when dichotomized (>2 mg/dL), showed significant differences between patients with and without choledocholithiasis.
Conclusions:
- Current adult criteria are insufficient for predicting pediatric choledocholithiasis.
- Conjugated bilirubin is a valuable biomarker for improving choledocholithiasis detection in children.
- Development of pediatric-specific guidelines is recommended for better stone prediction.
Background And Aims:
The management of suspected choledocholithiasis remains a challenge in pediatric endoscopy. Several recommendations are available for adult patients; however, it is unknown which pediatric patients are most likely to benefit from ERCP for evaluation of choledocholithiasis. The primary aim of this study was to evaluate adult-based criteria in the evaluation of pediatric patients with choledocholithiasis. A secondary aim was to evaluate the role of conjugated (or direct) bilirubin to improve the sensitivity of detecting choledocholithiasis.
Methods:
This was a prospective multicenter study in pediatric patients as part of the Pediatric ERCP Database Initiative (PEDI) with additional post-hoc analysis of updated guidelines. Patients <19 years of age undergoing ERCP for suspected choledocholithiasis or gallstone pancreatitis were enrolled at participating sites.
Results:
Ninety-five patients were enrolled (69 with choledocholithiasis confirmed at ERCP and 26 with no stones at ERCP). Adverse event rates were similar in both groups. Specificity ranged from 27% to 91% using adult guidelines, but a sensitivity of only 20% to 69%. The were no significant differences between the 2 groups using preprocedure transabdominal US (P = 1.0). Significant differences between groups were identified using either the total or conjugated bilirubin (P = .02). There was also a significant difference between the stone and no-stone groups when conjugated bilirubin was dichotomized to >2 mg/dL (P = .03).
Conclusions:
Abdominal imaging and laboratory indices may be used to predict pediatric choledocholithiasis with varying sensitivity and specificity. Pediatric-specific guidelines may allow for improved stone prediction compared with existing adult recommendations.
