Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children

Implementation of a Surgery-first Approach to Pediatric Choledocholithiasis

BACKGROUND

In choledocholithiasis, the obstructed common bile duct (CBD) requires clearance either via endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOC) and common bile duct exploration (CBDE) during cholecystectomy. We hypothesized that patients with primary cholecystectomy (PC) and IOC/CBDE will have improved clinical outcomes when compared to primary ERCP (PE) patients.

METHODS

We performed a retrospective cohort study of pediatric choledocholithiasis patients who underwent treatment at our institution between 2019 and 2023. We compared clinical and cost outcomes between PC and PE cohorts and assessed protocol compliance.

RESULTS

We analyzed 36 PC patients and 40 PE patients. Among PC patients, 52.7% underwent postoperative ERCP of which 47.4% were negative for CBD stone. Duct-clearing procedure varied between PC and PE groups, respectively, in terms of ERCP (36.1% vs. 65%), IOC/CBDE (36.1% vs. 2.5%), and spontaneous clearance (27.8 vs. 32.5%) (p < 0.001). One-third of PC patients had CBD clearance via IOC and flush and 16.7% had successful IOC/CBDE. PC patients had longer median combined surgical/procedural anesthesia duration (186 vs. 170.5 min, p = 0.318). There were no significant differences between PC and PE patients in terms of cost of surgery/procedures or overall admission.

CONCLUSION

Most PC patients achieved duct clearance via IOC and spontaneous means. PC has the potential to enable earlier cholecystectomy and avoid postoperative ERCP altogether. In the setting of failed CBDE, combining a PC strategy with non-interventional monitoring may eliminate unnecessary postoperative ERCPs. Future studies should assess outcomes associated with an amended surgery-first protocol in a larger cohort.

LEVEL OF EVIDENCE

II.

Reducing MRCP Utilization Through a "Surgery First" Approach for Pediatric Choledocholithiasis: A CARES Working Group Retrospective Study

BACKGROUND

Choledocholithiasis in children is rising and frequently managed with an endoscopy-first (EF) approach that utilizes endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Magnetic resonance cholangiopancreatography (MRCP) is a resource intensive modality that often precedes ERCP to gain further assurance of choledocholithiasis prior to intervention. MRCP can lead to a longer length of stay (LOS) and strain healthcare resources. We hypothesized that the use of MRCP is decreased with a surgery-first (SF) approach.

METHODS

The Choledocholithiasis Alliance for Research, Education, and Surgery (CARES) Working Group conducted this retrospective study on pediatric patients with suspected choledocholithiasis. SF patients underwent LC + intraoperative cholangiogram (IOC) ± laparoscopic common bile duct exploration (LCBDE). Imaging studies included ultrasound (US), MRCP, and computed tomography (CT).

RESULTS

From seven institutions, 357 pediatric patients were identified. The SF (n = 220) group received fewer imaging studies then EF (n = 137) (1.29 vs. 1.62; p < 0.05). US was more commonly employed and the number of US and CT scans was similar. The SF group had lower MRCP utilization than EF (29% vs. 59%; p < 0.05). EF patients that received an MRCP had the longest LOS (4.0 d [2.4, 6.3]) compared to SF that did not (1.9 d [1.2, 3.2]) (p < 0.05).

CONCLUSION

Children with choledocholithiasis managed with an EF approach receive more diagnostic imaging, especially MRCP. While MRCP remains a powerful diagnostic tool, a surgery-first approach can minimize the resource utilization and LOS associated with magnetic resonance imaging.

LEVEL OF EVIDENCE

Level III.

Spare the Needle, Discharge the Child: Trending Post-Op Labs After Laparoscopic Common Bile Duct Exploration in Pediatric Patients Is Not Helpful

Laparoscopic common bile duct exploration (LCBDE) utility in management of choledocholithiasis may decrease length of stay and patient cost, but postoperative management remains widely debated. We examined periprocedural LFTs for patients undergoing LCBDE and endoscopic retrograde cholangiopancreatography (ERCP) speculating for trend existence after successful LCBDE. We hypothesized that postoperative LCBDE LFTs would not downtrend even after successful ductal clearance. We identified 99 patients under 18 who underwent ERCP or LCBDE with at least one pre- and post-procedural LFT. Periprocedural LFTs between groups were compared using Wilcoxon signed-rank tests. The 22 ERCP patients demonstrated a significant downtrend across Tbili (P < .001), AST (P = .001), ALT (P = .002), and ALP (P < .001). The 27 LCBDE patients demonstrated a significant downtrend in Tbili (P = .002) only, while AST (P > .05), ALT (P > .05), and ALP (P > .05) were nonsignificant. Lack of consistent downtrend in the LCBDE group raises doubt regarding the utility of postoperative LFTs for post-procedural management.

Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis

BACKGROUND

Gallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients.

METHODS

We conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors.

RESULTS

Eighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4-17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively.

CONCLUSION

Pediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD.

LEVEL OF EVIDENCE

Level II, retrospective study.

Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of "New Technologies"

BACKGROUND

In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children.

AIMS

This study aims to describe current indications and timing for LC in pediatric patients.

METHODS

Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020-2023.

RESULTS

In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores.

CONCLUSIONS

Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent.

Machine learning to predict pediatric choledocholithiasis: A Western Pediatric Surgery Research Consortium retrospective study

BACKGROUND

The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm.

METHODS

A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset.

RESULTS

A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935.

CONCLUSION

This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis.