Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients
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Goeto Dantes, Jessica L. Rauh, Savannah Smith, Eunice Aworanti, Marshall W. Wallace, Irving J. Zamora, Derek Krinock, Sabina Siddiqui, Amanda Witte, Katherine Flynn-O-Brien, Utsav M. Patwardhan, Romeo C. Ignacio, Eric Knauer, Lucas Neff, Hanna Alemayehu
Background: In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance.
Methods: A multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared.
Results: 724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03).
Conclusion: LCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults.
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Can a surgery first approach be used for the management of cholodocholithiasis in children? I'm Alex Halpern, a research fellow from Children's National, and this is an article that you should know. To try and answer this question, Dantesetal performed a multi-center retrospective review looking at pediatric and adult patients treated for cholodocholithiasis between 2018 and 2024. 724 patients were included. The surgery first approach with upfront laparoscopic cholecystectomy with intraoperative cholangiogram was performed in 201 pediatric patients and 169 adult patients. In the surgery first group, laparoscopic common bile duct exploration was attempted in 84 kids and 140 adults. Common bile duct exploration success was higher in pediatric than adult patients with similar complication rates. So it seems like a surgery first approach can be a safe and effective tool for managing chodocholithiasis in pediatric patients. Does this information change your practice? Let us know what you think in the comments below.