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Updated: May 23, 2025
Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery
Published on: February 10, 2023
Approach to biliary tree clearance in pediatric patients undergoing cholecystectomy: insights from a tertiary
Tal Weiss1,2, Yael Dreznik3,4, Maya Paran3,4
1Faculty of Medicine, Tel Aviv University, Kiryat HaUniversita, Ramat Aviv, Tel Aviv, Israel. Magertal@gmail.com.
Insights
Predictors for common bile duct (CBD) stones in pediatric cholecystectomy patients were identified. Adult guidelines are applicable, with elevated bilirubin as a key high-risk indicator for CBD stones in children.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Hepatology
Background:
- Cholecystectomy rates are rising in children, yet standardized perioperative biliary tree clearance protocols are lacking.
- The applicability of adult guidelines for managing common bile duct (CBD) stones in pediatric patients remains unclear.
Purpose of the Study:
- To determine predictors of CBD stones in pediatric patients undergoing cholecystectomy.
- To assess the relevance of adult guidelines for CBD stone management in children.
Main Methods:
- Retrospective study of 177 pediatric patients undergoing cholecystectomy for cholelithiasis (2011-2024).
- Analysis of demographic and clinical data, including elevated bilirubin (defined as >4 mg/dL with >20% conjugated).
- Evaluation of CBD stones detected via ERCP or intraoperative cholangiography and post-cholecystectomy complications.
Main Results:
- Sixteen patients (9%) had CBD stones.
- Elevated bilirubin, dilated CBD, and primary imaging filling defects were significantly associated with CBD stones (p < 0.001).
- The 2019 ASGE guidelines showed 56.2% sensitivity and 91.1% specificity; adjusting for elevated bilirubin as high-risk improved sensitivity to 68.8% and specificity to 87.6%.
Conclusions:
- The 2019 ASGE guidelines appear applicable to pediatric patients.
- Elevated bilirubin should be considered an independent high-risk feature for CBD stones in children.
Introduction:
Despite the increasing rate of cholecystectomy in pediatric patients, no standardized protocols for perioperative biliary tree clearance in children exist and the applicability of adult guidelines to pediatric patients remains uncertain.
Aim:
To identify predictors for CBD stones in pediatric patients undergoing cholecystectomy and to evaluate the applicability of adult guidelines for children.
Materials And Methods:
We conducted a retrospective study on pediatric patients who underwent cholecystectomy for cholelithiasis at a tertiary pediatric medical center from 2011 to 2024. Medical records were reviewed for demographic and clinical characteristics. Elevated bilirubin was defined as above 4 mg/dL with > 20% conjugated. The outcomes measured included the presence of CBD stones detected by ERCP or intraoperative cholangiography and post-cholecystectomy complications due to retained stones.
Results:
A total of 177 patients were included in the study, with a median age of 13.4 years (IQR 9, 16.4). Sixteen patients (9%) were diagnosed with CBD stones. Elevated bilirubin, dilated CBD, and filling defects on primary imaging were strongly associated with CBD stones (50.0% vs. 9.9%, p < 0.001, 62.5% vs. 9.3%, p < 0.001, 43.8% vs. 4.4%, p < 0.001). The 2019 ASGE guidelines had a sensitivity of 56.2% and a specificity of 91.1% for predicting CBD stones. Adjusting the guidelines to classify elevated bilirubin as an independent high-risk feature improved sensitivity to 68.8%, with a slight reduction in specificity to 87.6%.
Conclusion:
Our study suggests that the 2019 ASGE guidelines are applicable to children. Based on our findings and previous data, it seems reasonable to classify bilirubin elevation as an independent high-risk feature.
