A Comparative Analysis of "Surgery First" vs. "Endoscopy First" for Pediatric Choledocholithiasis Presenting at the...

Area of Science:

• Pediatric Surgery
• Gastroenterology
• Biliary Tract Diseases

Background:

• Choledocholithiasis in children is often treated with an "endoscopy first" (EF) strategy, involving ERCP and LC under separate anesthetics.
• Endoscopic retrograde cholangiopancreatography availability is limited at the end of the week (EoW).
• A "surgery first" (SF) approach using LC, IOC, and LCBDE may reduce length of stay (LOS) and time to definitive intervention (TTDI).

Purpose of the Study:

• To compare the outcomes of "surgery first" (SF) versus "endoscopy first" (EF) strategies for pediatric choledocholithiasis.
• To evaluate the impact of presentation timing (work week vs. end of week) on LOS and TTDI.
• To determine the effectiveness of laparoscopic common bile duct exploration (LCBDE) within the SF approach.

Main Methods:

• Retrospective single-center cohort study (2018-2023) of pediatric patients with suspected choledocholithiasis.
• Patients were categorized by presentation timing: work week (WW) or end of week (EoW).
• Comparison of LOS and TTDI between SF and EF groups, with TTDI defined as time to LC.

Main Results:

• 88 patients were analyzed; 61 in SF and 27 in EF groups.
• SF groups showed significantly shorter mean LOS for both WW and EoW presentations.
• SF approach led to a trend of shorter TTDI and required fewer procedures (69% vs. 100% for EF).

Conclusions:

• Pediatric choledocholithiasis presenting at the EoW is associated with longer LOS and TTDI, particularly with an EF pathway.
• The SF approach offers reduced LOS and fewer procedures, irrespective of presentation timing.
• LCBDE demonstrated high success rates in the SF group, regardless of presentation timing.