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Reducing MRCP Utilization Through a "Surgery First" Approach for Pediatric Choledocholithiasis: A CARES Working Group
Jessica L Rauh1, Goeto Dantes2, Hanna Alemayehu2
1Wake Forest School of Medicine, Winston Salem, USA.
Insights
A surgery-first approach for pediatric choledocholithiasis reduces magnetic resonance cholangiopancreatography (MRCP) use and length of stay. This strategy minimizes healthcare resource utilization compared to the endoscopy-first method.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Diagnostic Imaging
Background:
- Choledocholithiasis (bile duct stones) in children is increasing.
- The endoscopy-first (EF) approach uses ERCP and LC, often preceded by MRCP.
- MRCP is resource-intensive and can prolong hospital stays.
Purpose of the Study:
- To evaluate if a surgery-first (SF) approach decreases MRCP utilization in pediatric choledocholithiasis.
- To compare resource utilization between SF and EF management strategies.
Main Methods:
- Retrospective study of pediatric patients with suspected choledocholithiasis.
- SF group: Laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) +/- laparoscopic common bile duct exploration (LCBDE).
- EF group: Endoscopic retrograde cholangiopancreatography (ERCP) followed by LC. Imaging included US, MRCP, CT.
Main Results:
- SF group (n=220) had fewer imaging studies than EF group (n=137).
- MRCP utilization was significantly lower in the SF group (29%) vs. EF group (59%).
- EF patients receiving MRCP had longer LOS (4.0 days) compared to SF patients without MRCP (1.9 days).
Conclusions:
- The endoscopy-first approach for pediatric choledocholithiasis leads to increased diagnostic imaging, particularly MRCP.
- A surgery-first approach can reduce MRCP use, healthcare resource strain, and length of stay.
Background:
Choledocholithiasis in children is rising and frequently managed with an endoscopy-first (EF) approach that utilizes endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Magnetic resonance cholangiopancreatography (MRCP) is a resource intensive modality that often precedes ERCP to gain further assurance of choledocholithiasis prior to intervention. MRCP can lead to a longer length of stay (LOS) and strain healthcare resources. We hypothesized that the use of MRCP is decreased with a surgery-first (SF) approach.
Methods:
The Choledocholithiasis Alliance for Research, Education, and Surgery (CARES) Working Group conducted this retrospective study on pediatric patients with suspected choledocholithiasis. SF patients underwent LC + intraoperative cholangiogram (IOC) ± laparoscopic common bile duct exploration (LCBDE). Imaging studies included ultrasound (US), MRCP, and computed tomography (CT).
Results:
From seven institutions, 357 pediatric patients were identified. The SF (n = 220) group received fewer imaging studies then EF (n = 137) (1.29 vs. 1.62; p < 0.05). US was more commonly employed and the number of US and CT scans was similar. The SF group had lower MRCP utilization than EF (29% vs. 59%; p < 0.05). EF patients that received an MRCP had the longest LOS (4.0 d [2.4, 6.3]) compared to SF that did not (1.9 d [1.2, 3.2]) (p < 0.05).
Conclusion:
Children with choledocholithiasis managed with an EF approach receive more diagnostic imaging, especially MRCP. While MRCP remains a powerful diagnostic tool, a surgery-first approach can minimize the resource utilization and LOS associated with magnetic resonance imaging.
Level Of Evidence:
Level III.
