Endoscopic Retrograde Cholangiopancreatography (ERCP) Findings in Pediatric Patients With Choledocholithiasis Justify a Surgery-First Approach: A Multi-Center Study
Bibliographic record
Abstract
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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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.002 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".