Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children?
OBJECTIVE
Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used preoperatively in adult patients with suspected choledocholithiasis. Cholelithiasis occurs much less often in children, and the indications for ERCP are not established. We hypothesized that the natural history of choledocholithiasis in children is spontaneous passage of stones through the papilla and that these children can be managed without routine preoperative ERCP.


METHODS
Retrospective analysis of patients treated over a 10-year period.


METHODS
Tertiary care children's hospital.


METHODS
All patients with cholecystectomy for biliary disease.


METHODS
Cholecystectomy; intraoperative cholangiography for suspected choledocholithiasis: hyperbilirubinemia, gallstone pancreatitis, and ultrasonographic evidence of common bile duct dilation or common bile duct stones; and postoperative ERCP for symptomatic choledocholithiasis: pain and jaundice.


METHODS
Incidence and complications of choledocholithiasis and frequency of ERCP.


RESULTS
One hundred patients (63 females) were studied. Indications included acute cholecystitis (10%), chronic cholecystitis (59%), gallstone pancreatitis (26%), and choledocholithiasis (5%). An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography-proven choledocholithiasis required ERCP for symptoms 24 hours after operation. One additional patient, who did not undergo intraoperative cholangiography, developed symptomatic choledocholithiasis and required ERCP. There were no choledocholithiasis- or ERCP-related complications.


CONCLUSIONS
This study suggests that choledocholithiasis occurs frequently in children and that spontaneous passage of common bile duct stones is common. This could explain the relatively high incidence of gallstone pancreatitis. Conservative management of choledocholithiasis is successful in the majority of patients. Routine preoperative or postoperative ERCP is usually not indicated.
Vrochides
Dionisios V
DV
Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, RI 02905, USA.
Sorrells
Donald L
DL
Kurkchubasche
Arlet G
AG
Wesselhoeft
Conrad W
CW
Tracy
Thomas F
TF
Luks
Francois I
FI
D000293:Adolescent; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data*; D002763:Cholecystectomy; D042883:Choledocholithiasis / Q000000981:diagnostic imaging* / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods*; D012189:Retrospective Studies; D012680:Sensitivity and Specificity