Balancing Endoscopy and Surgery in Choledocholithiasis: A 12-Year Real-World Analysis From a Brazilian Tertiary...

Background Choledocholithiasis is a common biliary disorder, with endoscopic retrograde cholangiopancreatography (ERCP) as the preferred therapy. However, anatomical complexity, prior surgery, or severe cholangitis often require surgical intervention. Data from the Latin American tertiary centers remain scarce. Objective To evaluate the real-world management of choledocholithiasis in a Brazilian university hospital over 12 years, comparing outcomes between ERCP and surgical approaches. Methods This was a retrospective, single-center study including a convenience sample of 251 consecutive patients treated between 2011 and 2023. Patients were stratified into exclusive ERCP, upfront surgery, or surgery following ERCP failure. Demographic, clinical, laboratory, and procedural variables were analyzed, focusing on complications, length of stay, and mortality. Results ERCP was performed exclusively in 77.8% of patients, while 22.2% required surgery, half after failed ERCP. Surgical patients had higher rates of previous cholangitis (46.4% and 42.9% vs. 26.7%, p=0.04) and prior abdominal surgery. Laboratory differences included lower international normalized ratio (INR) in upfront surgery (p<0.001) and higher aspartate aminotransferase and alanine aminotransferase (AST/ALT) in ERCP patients (p=0.003 and p=0.002). ERCP-related complications occurred in 9% of procedures, while surgical groups showed higher complication rates (32.1% upfront, 25% after ERCP vs. 12.3% ERCP-only, p=0.01). Hospitalization was significantly longer in surgical patients (9 ± 4.5 and 12 ± 12.3 days vs. 4.7 ± 5.7 days, p=0.0002), whereas ICU stay did not differ (p=0.46). In-hospital mortality rates were 5.1% (ERCP), 7.1% (upfront surgery), and 8.3% (surgery after ERCP), with no significant difference between groups (p=0.85). Conclusions Our findings represent institutional real-world experience, highlighting ERCP as the first-line therapy while surgery remains essential in complex or refractory cases. Conclusions are limited by the retrospective design and potential selection bias. Strengthened referral pathways and early risk stratification are essential to optimize outcomes in public healthcare systems.