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Endoscopic Retrograde Cholangiopancreatography (ERCP) Findings in Pediatric Patients With Choledocholithiasis Justify
Alison Lehane1, Jessica L Rauh1, Goeto Dantes2
1Wake Forest School of Medicine, Winston-Salem, NC, USA.
Insights
A surgery-first approach for pediatric choledocholithiasis may be more efficient than endoscopy-first. Most pediatric patients with common bile duct stones could be treated with surgery alone, avoiding unnecessary Endoscopic Retrograde Cholangiopancreatography (ERCP).
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Biliary Tract Disease
Background:
- Pediatric choledocholithiasis management traditionally uses an endoscopy-first approach (ERCP before LC).
- ERCP poses risks (pancreatitis, bleeding, infection, perforation) and may be unnecessary if stones pass spontaneously.
- A surgery-first approach (IOC, LCBDE, power flushing, glucagon) offers an alternative pathway.
Purpose of the Study:
- To evaluate Endoscopic Retrograde Cholangiopancreatography (ERCP) findings in pediatric patients with choledocholithiasis.
- To characterize the nature and burden of common bile duct stones in this population.
- To determine the proportion of cases suitable for a surgery-first approach.
Main Methods:
- Retrospective, multi-center study of 127 pediatric patients (≤18 years) undergoing ERCP before LC.
- Data reviewed from seven children's hospitals, including imaging, ERCP findings, and stone characteristics.
- ERCP findings categorized (sludge, small, medium, large stones, or absent). Cases with sludge, small/medium stones, or negative findings deemed amenable to surgery-first.
Main Results:
- 69% of patients had ERCP findings manageable with surgery-first techniques.
- Among these, 19% had sludge, 46% stones, 24% sludge and stones, and 11% no obstruction.
- Large stones (>8 mm) were infrequent, found in only 8% of cases.
Conclusions:
- Findings support a surgery-first approach as a potential paradigm shift for pediatric choledocholithiasis.
- ERCP should be reserved for select cases where surgical clearance fails or cholangitis is present.
- This approach may reduce hospital stays, procedural risks, and costs while maintaining efficacy.
Background:
Pediatric choledocholithiasis is traditionally managed with an endoscopy-first approach, where Endoscopic Retrograde Cholangiopancreatography (ERCP) is performed before laparoscopic cholecystectomy (LC). However, ERCP carries risks such as pancreatitis, bleeding, infection, and perforation, and may even be an unnecessary procedure should stones pass spontaneously. An alternative surgery-first approach, utilizing intraoperative cholangiogram (IOC), laparoscopic common bile duct exploration (LCBDE), power flushing, and glucagon, may offer a more efficient treatment pathway. This study aims to evaluate ERCP findings in pediatric patients undergoing an endoscopy-first pathway to characterize the nature and burden of stone disease in the common bile duct. Our ultimate goal is to determine the proportion of cases that could have been successfully managed with a surgery-first approach.
Methods:
This retrospective, multi-center study analyzed 127 pediatric patients (≤18 years) who underwent ERCP prior to LC for suspected choledocholithiasis. Data from seven children's hospitals were reviewed, including imaging studies, ERCP findings, and stone characteristics. ERCP findings were categorized as sludge, small (<4 mm), medium (5-7 mm), large (>8 mm), or absent stones. Cases with sludge, small/medium stones, or negative ERCP findings were considered amenable to a surgery-first approach as they are known to be manageable with intraoperative techniques.
Results:
69 % of patients had ERCP findings that were amenable to transcystic surgical maneuvers without preoperative ERCP. Among those, 19 % had only sludge, 46 % had only stones, 24 % had sludge and stones, and 11 % had no evidence of obstruction. Large stones (>8 mm) were found in only 8 % of cases.
Conclusion:
The findings support a surgery-first has potential for a paradigm shift as standard of care for pediatric choledocholithiasis, with ERCP reserved for select cases where surgical clearance fails or cholangitis is present. Adoption of this approach could reduce hospital stays, procedural risks, and healthcare costs while maintaining high efficacy in duct clearance. Prospective studies are warranted to refine clinical guidelines.
Level Of Evidence:
IV.
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