Surgery-first versus endoscopy-first for pediatric choledocholithiasis: Systematic review and meta-analysis
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Giovanna Macanhã Scremin1, Lucas Monteiro Delgado2, Wellgner Fernandes Oliveira Amador3
1Pontifical Catholic University of Paraná, Curitiba, Brazil.
Background:
The incidence of pediatric choledocholithiasis is rising, yet the optimal initial treatment strategy remains debated. Clinicians must choose between an endoscopy-first approach (preoperative ERCP followed by laparoscopic cholecystectomy) and a surgery-first strategy (laparoscopic cholecystectomy with intraoperative cholangiography and bile duct exploration). Direct pediatric data comparing these two strategies remain scarce, and clinical decision-making therefore continues to rely heavily on evidence extrapolated from adult populations.
Methods:
We conducted a systematic review and meta-analysis of studies comparing surgery-first versus endoscopy-first management of pediatric choledocholithiasis, following PRISMA 2020 guidelines. MEDLINE, Embase, and Cochrane databases were searched from inception to December 2025. Pooled estimates were calculated utilizing risk ratios (RR) and mean differences (MD) via random-effects models with the REML estimator. Risk of bias was assessed using the ROBINS-I tool.
Results:
Surgery-first management reduced hospital length of stay (MD -1.61 days; 95% CI -2.50 to -0.71; p < 0.001) but correspondingly increased operative time (MD 31.45 min; 95% CI 15.60 to 47.29; p < 0.001). We found no significant difference regarding overall complications (RR 0.46; 95% CI 0.09 to 2.33; p = 0.22) or bleeding (RR 0.28; 95% CI 0.06 to 1.32; p = 0.11). Surgery-first patients demonstrated a lower risk of postoperative pancreatitis (RR 0.21; 95% CI 0.06 to 0.73; p = 0.01) and 30-day readmission (RR 0.42; 95% CI 0.18 to 0.95; p = 0.04).
Conclusions:
Surgery-first was consistently associated with lower rates of postoperative pancreatitis, shorter hospital length of stay, and fewer 30-day readmissions, at the cost of longer operative time. Because the evidence remains observational, with low-to-very-low certainty by GRADE, these associations should be interpreted as hypothesis-strengthening rather than definitive. Surgery-first may be a reasonable first-line option for appropriately selected children at centers with laparoscopic biliary expertise, pending higher-quality prospective data.
