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ERCP first vs. surgery first: A comparative perspective in pediatric choledocholithiasis
Wesley Judy1, Micaela K Gomez2, Quin Liu3
1University of California San Diego, Department of Pediatrics, 9500 Gilman Dr, La Jolla, CA, 92093, USA; Rady Children's Hospital, Division of Gastroenterology, 3020 Children's Way, San Diego, CA, 92123, USA.
Insights
Pediatric choledocholithiasis management involves two main strategies: "endoscopy-first" or "surgery-first" (SF). The SF approach may offer advantages, but standardized guidelines are lacking for this rare condition.
Area of Science:
- Pediatric Gastroenterology and Surgery
- Hepatobiliary Diseases
Background:
- Pediatric choledocholithiasis, though rare, is increasingly diagnosed.
- Current management strategies include endoscopy-first and surgery-first (SF) approaches.
- No standardized treatment algorithm exists, leading to varied clinical practice.
Purpose of the Study:
- To compare the efficacy and resource utilization of endoscopy-first versus surgery-first approaches for pediatric choledocholithiasis.
- To analyze the clinical outcomes and healthcare resource impact of each management strategy.
Main Methods:
- This review presents a point-counterpoint analysis of existing literature.
- It examines the components of both endoscopy-first (preoperative ERCP followed by cholecystectomy) and surgery-first (laparoscopic cholecystectomy with intraoperative cholangiogram and CBD exploration) approaches.
- The review synthesizes data on clinical outcomes and healthcare resource utilization.
Main Results:
- The surgery-first approach is a single-stage procedure with potential advantages highlighted in recent studies.
- Both approaches have distinct procedural steps and indications.
- Management decisions are significantly influenced by institutional capabilities and practice patterns.
Conclusions:
- Further research is essential to establish evidence-based guidelines for pediatric choledocholithiasis management.
- A multidisciplinary approach is crucial for developing consensus-driven treatment algorithms.
- Standardization of care could optimize clinical outcomes and resource allocation for pediatric choledocholithiasis.
Abstract:
Pediatric choledocholithiasis is a rare but increasingly recognized disease process that is predominantly managed with either an "endoscopy-first" or "surgery-first" (SF) approach. In the endoscopy-first approach, a preoperative endoscopic retrograde cholangiopancreatography is performed with subsequent cholecystectomy. In contrast, the surgery-first approach is a single-stage procedure that includes a laparoscopic cholecystectomy and intraoperative cholangiogram, followed by a laparoscopic common bile duct exploration when indicated. Recent studies have highlighted the potential advantages of the SF approach. However, no standardized treatment algorithm exists, and institutional capabilities and practicing patterns heavily influence management decisions. This point-counterpoint review explores both approaches, analyzing their effects on clinical outcomes and healthcare resources. Continued research and a multidisciplinary approach are needed to develop consensus-driven treatment algorithms.
