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"Surgery First" vs. "Endoscopy First" for Pediatric Choledocholithiasis Presenting at the End of the Week - A CARES

Garrett Reid1, Jessica L Rauh1, Elizabeth Wood1

  • 1Wake Forest School of Medicine, Winston Salem, USA.

Journal of Pediatric Surgery
|October 6, 2024
PubMed

Insights

A surgery-first approach for pediatric choledocholithiasis significantly reduces hospital stay and time to treatment compared to endoscopy-first strategies. This approach is effective regardless of patient presentation timing, leading to fewer procedures and improved efficiency.

Area of Science:

  • Pediatric Surgery
  • Gastroenterology
  • Hepatobiliary Surgery

Background:

  • Choledocholithiasis in children is often treated with an endoscopy-first (EF) strategy involving ERCP and LC.
  • ERCP availability can be limited on weekends, potentially delaying care.
  • A surgery-first (SF) approach may offer advantages in managing pediatric choledocholithiasis.

Purpose of the Study:

  • To compare the efficacy of SF versus EF strategies for pediatric choledocholithiasis.
  • To evaluate the impact of presentation timing (work week vs. end of week) on treatment outcomes.
  • To determine differences in length of stay (LOS) and time to definitive intervention (TTDI).

Main Methods:

  • Multicenter, retrospective cohort study of pediatric patients (2018-2023) with suspected choledocholithiasis.
  • Defined work week (WW) as Monday-Thursday admission.
  • TTDI calculated as time to LC or postoperative ERCP.

Main Results:

  • 354 patients analyzed; 61% treated with SF, 39% with EF.
  • SF associated with significantly shorter LOS (60.2h WW, 58.3h EoW) compared to EF (88.5h WW, 93.6h EoW).
  • SF significantly decreased TTDI (26.4h WW, 28.9h EoW) versus EF (61.4h WW, 72.8h EoW).
  • Majority of SF patients (79%) had one procedure, while all EF patients had at least two.

Conclusions:

  • Pediatric choledocholithiasis presenting at the end of the week (EoW) leads to longer LOS and TTDI, especially with an EF approach.
  • A surgery-first approach reduces procedures, TTDI, and LOS for pediatric choledocholithiasis.
  • SF is a more efficient strategy regardless of presentation timing.
Abstract

Keywords:
CholedocholithiasisCommon bile duct explorationPediatric

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