# Approach to biliary tree clearance in pediatric patients undergoing cholecystectomy: insights from a tertiary hospital

## TL;DR

This study examines how to identify children with gallstones in the bile duct before gallbladder surgery and finds that adult guidelines can be adapted for pediatric patients.

## Contribution

The study adapts adult guidelines for identifying bile duct stones in children and identifies bilirubin elevation as a key predictor.

## Key findings

- Elevated bilirubin, dilated CBD, and filling defects were strongly associated with CBD stones in pediatric patients.
- Adjusting the ASGE guidelines to consider bilirubin elevation improved sensitivity for predicting CBD stones.
- The 2019 ASGE guidelines showed reasonable applicability to children with a sensitivity of 56.2% and specificity of 91.1%.

## Abstract

Despite the increasing rate of cholecystectomy in pediatric patients, no standardized protocols for perioperative biliary tree clearance in children exist and the applicability of adult guidelines to pediatric patients remains uncertain.

To identify predictors for CBD stones in pediatric patients undergoing cholecystectomy and to evaluate the applicability of adult guidelines for children.

We conducted a retrospective study on pediatric patients who underwent cholecystectomy for cholelithiasis at a tertiary pediatric medical center from 2011 to 2024. Medical records were reviewed for demographic and clinical characteristics. Elevated bilirubin was defined as above 4 mg/dL with > 20% conjugated. The outcomes measured included the presence of CBD stones detected by ERCP or intraoperative cholangiography and post-cholecystectomy complications due to retained stones.

A total of 177 patients were included in the study, with a median age of 13.4 years (IQR 9, 16.4). Sixteen patients (9%) were diagnosed with CBD stones. Elevated bilirubin, dilated CBD, and filling defects on primary imaging were strongly associated with CBD stones (50.0% vs. 9.9%, p < 0.001, 62.5% vs. 9.3%, p < 0.001, 43.8% vs. 4.4%, p < 0.001). The 2019 ASGE guidelines had a sensitivity of 56.2% and a specificity of 91.1% for predicting CBD stones. Adjusting the guidelines to classify elevated bilirubin as an independent high-risk feature improved sensitivity to 68.8%, with a slight reduction in specificity to 87.6%.

Our study suggests that the 2019 ASGE guidelines are applicable to children. Based on our findings and previous data, it seems reasonable to classify bilirubin elevation as an independent high-risk feature.