P1.085: Surgery First in Pediatric Hemolytic Disease: A Smarter Approach to Choledocholithiasis?

Background: Hemolytic disease is the second most common cause of biliary stones in the pediatric population. A surgery-first (SF) approach, utilizing laparoscopic common bile duct exploration (LCBDE) when needed, has demonstrated improved outcomes compared to endoscopic retrograde cholangiopancreatography (ERCP) first (EF) in children with choledocholithiasis. SF and EF have not been directly compared in children with hemolytic disease. Given the higher surgical, procedural, and anesthetic risks in this patient population, we aimed to evaluate the outcomes of SF vs EF in this cohort.

Methods: We conducted a multi-institutional retrospective review of patients < 18 years of age diagnosed with choledocholithiasis between 2012 and 2025. Demographic data, clinical characteristics, and outcomes, including duct clearance rate, length of stay, and complications, were recorded. We compared SF vs EF in the hemolytic disease population and compared outcomes of the hemolytic to non-hemolytic cohort. Wilcoxon rank sum test was performed on continuous variables, and Pearson’s Chi-squared test and Fisher’s exact test were used to analyze categorical variables, with a significance level of 0.05.

Results: Among 438 children with choledocholithiasis, the majority were females (71.7%), with a median age of 15.2 years (IQR: 13.10, 16.80). Of these, 54 had a hemolytic disease, including HbSS (55.6%), hereditary spherocytosis (27.8%), HbSC (7.4%), HbSS/BO (3.7%), beta thalassemia trait (1.9%), hemoglobin E beta zero thalassemia (1.9%) and Hb-Mainz hemolytic anemia (1.9%). Patients with a hemolytic disease were younger, with a lower BMI, more likely to be male, and less likely to have cholecystitis.). The proportion of patients with choledocholithiasis, proportion with SF and EF approach, surgical and endoscopic complication rates, and length of stay were similar between patients with or without hemolytic diseases. Patients with hemolytic diseases had a shorter operative time than those without, but were more likely to return to the emergency department (14.8% vs 5.5%, p=0.017). Within the hemolytic diseases cohort, patients treated with a SF approach had a shorter length of hospital stay (2 days vs 6 days, p=0.009), while their rate of duct clearance (100% vs 100%, p=1.000), operative time (89 min vs 84 min, p=0.900), ED revisit rate (21.1% vs 0.0%, p=0.088), readmission rate (5.4% vs 0.0%, p=1.000), surgical complications (2.6% vs 12.5% p=0.206), and endoscopic complications (0.0% vs 12.5%, p=0.084) were similar.

Conclusion: A surgery first approach, with laparoscopic common bile duct exploration when necessary, is effective in the management of choledocholithiasis in children with hemolytic disease. The shorter length of hospital stay with the surgery first approach in children with choledocholithiasis is also demonstrated in the hemolytic diseases population, without increased complications.