Although biliary disease remains uncommon in children, the incidence of pediatric cholelithiasis has increased significantly in recent years, with gallstones now affecting approximately 1.9 % to 4 % of pediatric patients.1,2 This increase is thought to be linked to the rising prevalence of pediatric obesity, with 19.3 % of children in the U.S. now classified as obese.3,4 Mirroring the increase in cholelithiasis, cases of pediatric choledocholithiasis are also on the rise. Over the past two decades, the proportion of cholecystectomies attributed to choledocholithiasis more than tripled from 1.9 % to 6 %.1

Managing choledocholithiasis in children remains challenging due to its infrequency, lack of standardized treatment guidelines, and limited availability of interventional pediatric gastroenterologists and surgeons in many regions.5 Traditionally, both adult and pediatric cases were primarily managed with a two-procedure or “endoscopy-first” (EF) approach consisting of an endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy. Recent studies have highlighted the potential advantages of a “surgery-first” (SF) approach, in which patients undergo a single procedure that consists of laparoscopic cholecystectomy with intraoperative cholangiogram and, if indicated, a transcystic laparoscopic common bile duct exploration (LCBDE). Reported benefits of a SF approach include reduced number of anesthetic events, fewer complications, decreased hospital length of stay, and reduced cost.5, 6, 7, 8, 9 Despite this, there is an ongoing debate about which strategy is more advantageous with limited high-quality data to guide the development of standardized pediatric treatment algorithms. This point-counterpoint review explores the advantages, limitations, and knowledge gaps of adopting an EF versus a SF approach, providing a framework for optimizing management strategies in pediatric choledocholithiasis.

While ERCP and IOC +/—LCBDE can diagnose and treat choledocholithiasis, magnetic resonance cholangiopancreatography (MRCP) is the preferred noninvasive diagnostic tool for definitively evaluating the biliary system before proceeding with invasive treatment modalities. However, MRCP has several drawbacks, including high cost, limited availability, potential treatment delay, and the need for sedation in younger children.

Proponents of a SF approach highlight that direct surgical intervention can reduce the reliance on pre-procedural imaging. A multi-center retrospective review found that MRCP utilization was significantly lower in children with choledocholithiasis managed with a SF approach when compared to an EF approach (29 % vs 59 %, p<0.05). Additionally, patients who underwent MRCP in the EF approach had the longest median length of stay (4 days), more than two days longer than patients managed with the SF approach and no MRCP.7

In contrast, two retrospective studies demonstrated that MRCP was utilized in only 21 % of patients with suspected choledocholithiasis before undergoing an ERCP (20 of 95 and 34 of 164, respectively).10,11 While no direct comparison was made between the SF and EF approaches in these studies, the lower MRCP use with EF management highlights significant variability in institutional practices. These studies demonstrate an approach that prioritizes clinical status and biochemical criteria to avoid unnecessary imaging without increasing the risk of missing choledocholithiasis. The higher MRCP utilization observed in Rauh et al. may reflect differences in patient selection, institutional reliance on pre-procedural imaging, and/or the limited availability of an pediatric advanced endoscopist. These practice variations emphasize the need for standardized, evidence-based risk stratification criteria to optimize MRCP utilization.

Efforts to reduce MRCP overuse in managing choledocholithiasis have been outlined in the American Society for Gastrointestinal Endoscopy (ASGE) 2019 guidelines; however, applicability to pediatric choledocholithiasis is limited. The Pediatric ERCP Database Initiative (PEDI) and the Western Pediatric Surgery Research Consortium (WPSRC) have examined laboratory parameters and imaging findings to predict choledocholithiasis in children. PEDI’s evaluation of 95 patients found conjugated bilirubin > 2 mg/dL to be most predictive of a common bile duct (CBD) stone; however, 38 % of children with CBD stones had conjugated bilirubin below 0.5 mg/dL.10 In a larger retrospective cohort of 973 patients, the WPSRC Choledocholithiasis Investigative Group developed predictive pediatric DUCT criteria that included a dilated CBD ≥ 6 mm, the presence of a CBD stone on ultrasound (US), and a total bilirubin ≥ 1.8 mg/dL. Patients were stratified into risk categories based on the cumulative presence of these factors, with the high-risk group (two or more factors) achieving a sensitivity of 59 % and a specificity of 94 %.12

Moving forward, the most effective strategy will be to shift from an overreliance on cross-sectional imaging to optimize patient risk stratification. By refining diagnostic algorithms to integrate clinical status, biochemical criteria, and ultrasonographic findings, clinicians can more accurately identify the pediatric patients who will benefit from therapeutic interventions. This will reduce costs and unnecessary imaging, help to streamline care, and improve patient outcomes.

ERCP with endoscopic sphincterotomy and stone extraction is successful in approximately 94 %-100 % of pediatric choledocholithiasis cases.8,10,13,14 Similarly, LCBDE demonstrates a fairly high success rate of 80 % to 92 % when performed by experienced surgeons.6,8,9,15 A study examining surgeons with varying experience levels found that the overall success rate for duct clearance decreased significantly to 53.3 %, but more experienced surgeons maintained a high success rate of 87.5 %.16 Like any procedure, LCBDE requires skill development. With adequate training and experience, multi-institutional studies suggest that both ERCP and LCBDE can achieve high rates of ductal clearance.

In a small, single-institutional study of children with choledocholithiasis, 36.1 % of patients in the SF cohort achieved stone clearance via IOC or LCBDE, 36.1 % with postoperative ERCP, and 27.8 % through spontaneous passage. Approximately half of the SF patients required a postoperative ERCP, but 47.4 % were negative for stones suggesting spontaneous clearance.17 In this study, half of the patients who failed stone clearance with IOC and flushing did not undergo LCBDE, potentially contributing to low ductal clearance rates and increased postoperative ERCP use. Nonetheless, these findings emphasize that ERCP is an important adjunct for children who fail IOC ± LCBDE.

Careful patient selection is essential to optimizing outcomes and minimizing treatment failures. Given the scarcity of pediatric data, insights from the adult literature serve as a valuable framework to guide clinical decision-making. Factors associated with difficult ductal clearance include the size, location, and number of stones, anatomical variations, and technical expertise. Understanding these factors is critical in determining the best therapeutic strategy for successful ductal clearance.

From a surgical perspective, the factors associated with LCBDE failure in adults include a small cystic duct diameter (<4 mm), larger stones (>6 mm), a stone-to-cystic duct ratio >1 making stone removal challenging, multiple stones (more than 3–5), and impacted stones.18,19 Other factors associated with increased failure rates in adults include elevated preoperative total bilirubin levels, higher preoperative C-reactive protein level, and the presence of pancreatitis.20

From the endoscopic perspective, the factors associated with ERCP failure include larger stones (≥15 mm) and the presence of more than four stones.21, 22, 23 Additionally, stones located in the intrahepatic duct, proximal bile duct, cystic duct, or those that are impacted pose greater challenges and have a higher rate of failure.21, 22, 23 Altered surgical anatomy from prior procedures, such as Roux-en-Y gastrojejunostomy or sphincteroplasty, further complicates endoscopic access.23 Although these studies do not specifically report endoscopist experience as an independent risk factor, it is reasonable to infer that less experienced endoscopists may encounter greater technical difficulties in achieving successful ductal clearance in more complex cases.

Given the paucity of data for children with choledocholithiasis, more pediatric-specific research is needed to identify factors associated with difficult ductal clearance, procedural failure, and success. However, given the current data limitations, careful consideration of these factors is critical for effective pre-procedural planning to better identify which patients would benefit from a SF approach versus an EF strategy and to anticipate potential challenges in ductal clearance.

Both ERCP and LC with IOC ± LCBDE are generally well-tolerated procedures with low complication rates. The complication rate for biliary ERCP is reported at 4.2-7.7 % with most being mild. Endoscopic complications include post-ERCP pancreatitis (PEP), bleeding, and stent migration - rarely, cholangitis and perforation.9,10,13,14,24,25

In contrast, LC has a complication rate of approximately 3.4 %.26 Surgical complications include retained gallstones, superficial or deep surgical site infections, bleeding, and, less commonly, bile duct strictures. Rarely, injury can occur to surrounding structures such as the liver, bile ducts, or small bowel. Incorporating IOC and LCBDE into LC has not been shown to increase overall surgical complication rates.8,9

When comparing complication rates of children with pediatric choledocholithiasis who underwent EF versus SF, several multi-center retrospective studies have shown that the SF group experienced fewer complications.6,8,9 For instance, one study reported a complication rate of 1.9 % in the SF group compared to 15.6 % in the EF group (p<0.05).8 Similarly, another study found that pediatric patients managed with EF had a higher rate of endoscopic complications (9.1 % vs 1 %, p<0.001). In comparison, surgical complications were similar between the two groups (3 % vs 1.5 %, p=0.86).9 This complication profile could reflect the inherent difficulties of performing ERCP in smaller patients and the lack of readily available advanced endoscopists at SF centers. However, these findings and their discrepancy of endoscopy complication rates are limited by the retrospective nature of these studies and the lack of randomized treatment assignments, which could lead to patient selection bias.