# Endoscopic bile duct stenting as preliminary treatment of complicated choledochal malformation before definitive surgery

## TL;DR

Endoscopic stenting before surgery helps manage complications in choledochal malformation, making laparoscopic surgery safer and more feasible.

## Contribution

Demonstrates the effectiveness of ERCP and stenting as a preliminary treatment before definitive surgery for complicated choledochal malformation.

## Key findings

- ERCP with stenting improved clinical outcomes in patients with complicated choledochal malformation.
- Laparoscopic resection was performed in 75% of patients after stenting, with low complication rates.
- Stenting allowed for a median 9-week delay in surgery without adverse effects.

## Abstract

Acute pancreatitis or obstruction is considered an indication for urgent surgery in patients with choledochal malformation. However, in this inflammatory stage, surgery can be challenging. Our approach is to treat the acute obstruction by endoscopic retrograde cholangiopancreatography (ERCP), papillotomy, and placement of a bile duct stent. Subsequently, surgical resection of choledochal malformation is performed after the inflammation has subsided.

In this retrospective study, we included all patients who underwent surgical resection in our department for choledochal malformation with prior ERCP between 12/2013 and 12/2024. Post‐ERCP data of patients who received additional stenting were analyzed.

Twenty patients (75% female) with a complicated choledochal malformation and a median age of 5.6 years (range 0.4–18.3 years) were included. Fourteen patients presented with biliary pancreatitis, six of these with an additional symptomatic cholelithiasis. Twelve patients with complicated choledochal malformation underwent papillotomy and stenting of the common bile duct with post‐interventional clinical improvement. Out of these, three underwent a second and two patients a second and a third ERCP with stent replacement before surgery. One patient received six ECRPs in another hospital before surgery. After a median interval of 9 weeks after stenting (range, 2–34 weeks), three patients (25%) received open and nine (75%) laparoscopic resections of the choledochal malformation, with two conversions to open surgery (22%) due to massive adhesions. Surgery was uneventful in all patients.

Our data suggest that preoperative ERCP and stenting of the common bile duct is a valid option for patients with choledochal malformation complicated by pancreatitis or obstruction, making a laparoscopic approach feasible in the majority of patients.

Left picture: ERCP before stent placement.

Right picture: ERCP after placement of two stents.

Choledochal malformation complicated by acute pancreatitis or obstruction is an indication for urgent surgery.Endoscopic retrograde cholangiopancreatography (ERCP) is a common diagnostic tool for choledochal malformation.Timing of surgery remains controversial.

Choledochal malformation complicated by acute pancreatitis or obstruction is an indication for urgent surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common diagnostic tool for choledochal malformation.

Timing of surgery remains controversial.

ERCP and bile duct stenting are a feasible first‐line treatment option in the acute phase of obstruction in patients with choledochal malformation.Laparoscopic surgery can be postponed safely after ERCP with low rates of complications.

ERCP and bile duct stenting are a feasible first‐line treatment option in the acute phase of obstruction in patients with choledochal malformation.

Laparoscopic surgery can be postponed safely after ERCP with low rates of complications.