Concurrent Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: a Safe Strategy in Pediatric Patients

Concurrent Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: a Safe Strategy in Pediatric Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Concurrent Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: a Safe Strategy in Pediatric Patients Agustina Santangelo, Antonella Scarpin, Francisco Imaz, Paula Luján Marino, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4016988/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Gallbladder disease incidence in the pediatric population and its complications have been consistently increasing. The standard treatment for choledocholithiasis involves performing endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). These therapeutic methods require pediatric patients to undergo two different procedures. This study aims to demonstrate the safety of performing ERCP and LC in a single session in patients diagnosed with choledocholithiasis. Design and Methods: A prospective cohort study was conducted on patients under 18 years diagnosed with choledocholithiasis. They were divided into two groups: the "intervention group" underwent simultaneous ERCP and LC, while the "control group" underwent ERCP and LC in two separate sessions. Results: The present study includes forty-two patients, with 27 assigned to the “intervention group” and 15 to the “control group”. The difference in the average anesthesia time between the two groups was significant (p=0.001). Two patients in the "control group" developed cholecystitis while awaiting LC. Discussion: Most patients endured both procedures without experiencing significant complications. The main goals were to reduce the total anesthesia duration and the morbidity associated with gallbladder stones. This prospective study, conducted at two centers, supports the safety of performing both procedures simultaneously in pediatric patients. ERCP Cholecystectomy choledocholithiasis anesthesia pediatrics. INTRODUCTION Gallbladder stones have become an established pathology in the pediatric population, with their incidence continually rising over the last 20 years [ 1 , 2 ]. Traditionally, their etiology was associated with prematurity, the use of parenteral nutrition, and hemolytic diseases. Currently, like adults, the association with metabolic syndrome and obesity is evident [ 1 ]. Correspondingly, complications of gallbladder stones, such as acute cholecystitis, acute pancreatitis, and choledocholithiasis, have also shown an increased incidence recently [ 1 , 2 ]. The standard treatment for choledocholithiasis, described in both adults and children, involves performing endoscopic retrograde cholangiopancreatography (ERCP) initially, with sphincterotomy and extraction of bile stones, followed by delayed laparoscopic cholecystectomy (LC). Some centers schedule LC 48 to 72 hours after ERCP, while others postpone it until a second hospitalization. Other therapeutic alternatives suggest intraoperative cholangiography (IOC) during LC, with exploration and instrumentation of the bile duct, and eventual postoperative ERCP [ 3 ]. Less frequently, a simultaneous laparoscopic and endoscopic procedure known as Rendezvous can be performed [ 4 ]. These therapeutic strategies subject pediatric patients to two distinct anesthesia and surgical procedures, which could be detrimental given the inherent complications of each. Moreover, this approach leads to additional hospitalization expenses [ 5 ] and raises the possibility of complications related to gallstone disease such as pancreatitis, cholecystitis, and recurrence of choledocholithiasis. Recently, some studies in the adult [ 6 , 7 , 8 ] and pediatric [ 5 , 9 ] populations were published in which both procedures were performed in a single anesthesia session. This study aims to demonstrate that performing ERCP and subsequent LC in a single anesthesia session is safe in pediatric patients diagnosed with choledocholithiasis. It assesses immediate and intermediate complications as the primary outcome and analyses total anesthesia and hospitalization times as secondary outcomes. DESIGN AND METHODS This study employed a non-randomized prospective cohort design, including patients from January 1, 2020, to June 1, 2023. It was conducted at two centers: Hospital de Niños Ricardo Gutiérrez (CABA, Argentina) and Hospital del Niño Prof. Dr. Ramon Exeni (San Justo, Buenos Aires, Argentina). Patients under 18 years with a diagnosis of symptomatic choledocholithiasis, showing biliary tract dilation as evidenced by ultrasonography (extrahepatic bile duct ≥ 6 mm) and confirmed by magnetic resonance cholangiopancreatography (MRCP), were included in this study. The patients were divided into two groups: the first group consisted of patients who underwent ERCP and LC during the same anesthesia session ("intervention group"). The second group comprised patients who underwent ERCP and LC in two separate sessions ("control group"). The assignment of patients to their respective groups was based on the availability of the surgeon and endoscopist, who was not a permanent staff member at either hospital. If all conditions to perform the procedures simultaneously were met, the patient was assigned to the "intervention group". However, if conditions were not met, the patient underwent two separate sessions and was part of the "control group". Furthermore, patients who were diagnosed with cholecystitis or pancreatitis at the time of choledocholithiasis diagnosis were also included in this cohort. All patients provided informed consent. Variables considered for this study included demographic and clinical data before the procedure, intervention details (ERCP and cholecystectomy times, total anesthesia time, ERCP outcomes), and postoperative data. The intervention was considered "successful" when both procedures could be performed in a single session. It was considered a "failure" when either the endoscopic procedure or the laparoscopic cholecystectomy could not be completed. Regarding secondary objectives, the total anesthesia time for the "control group" was calculated by adding the minutes for each intervention (ERCP anesthesia time + LC anesthesia time). Statistical analyses Statistical analyses were performed using SPSS Statistics-25 software (IBM Statistics for Windows). The Shapiro-Wilk test was applied to assess the data distribution. Results indicated that the data did not follow a normal distribution (p < 0.05). Considering the data distribution and the sample sizes of the clinical group and control group, non-parametric statistics were chosen to study the differences between the groups. The Mann-Whitney U test, a non-parametric statistic, was employed to examine differences in total anesthesia times and times until oral tolerance between the groups. In all cases, p-values less than 0.01 were considered significant. Technical details of the procedures All patients underwent general anesthesia with endotracheal intubation and received prophylactic antibiotic therapy with intravenous ampicillin-sulbactam (150 mg/kg/day) in a single dose. Endoscopic procedure: Patients were positioned in the left lateral decubitus position. An Olympus duodenoscope with a 4.2 working channel was used to access the second part of the duodenum for papillotomy and cannulation with a hydrophilic guide. An iodinated contrast medium was injected (cholangiography) to map the biliary tract and identify any stones and their characteristics. The method for stone extraction varied based on the type, size, and quantity, using either a Dormia basket or a stone extraction balloon. All procedures were performed by the same endoscopic surgeon, who was responsible for evaluating and executing the procedure. Surgical procedure: Patients were placed in the dorsal decubitus position. Following the American technique, standard LC was performed with safety parameters according to Strasberg's criteria [ 10 ], using four ports (one umbilical for the optic, one epigastric, and two in the right flank). All patients were operated on by pediatric surgery residents and staff surgeons. RESULTS The study comprised 42 patients: 27 in the “intervention group” and 15 in the “control group”. Among them, 25 patients were treated at Hospital de Niños Ricardo Gutiérrez, while the remaining 17 received treatment at Hospital del Niño “Prof. Dr. Ramón Exeni”. The groups were similar in terms of age and gender. Most patients were overweight or obese at the time of the study: 38.09% overweight and 28.57% obese, based on z-scores and percentiles determined by the Sociedad Argentina de Pediatría (SAP) [ 11 ]. Most patients were categorized as ASA II in the anesthesia risk stratification. Demographic data for both groups is summarized in Table 1 . Table 1 Demographic data Characteristics Total (N = 42) Intervention (N = 27) Control (N = 15) Statistic p Age (years) M = 13,88 (SD = 1,89) M = 13,44 (SD = 1,80) M = 14,66 (SD = 1,83) U = 289,5 0,02 Range: 10–17 Range: 10–17 Range: 10–17 Gender Feminine 61,90% (N = 26) 70,37% (N = 19) 46,67% (N = 7) X 2 = 2,29 0,13 Masculine 38.10% (N = 16) 29,63% (N = 8) 53.33% (N = 8) Weight (Kg) M = 65,21 (SD = 11,16) M = 63,48 (SD = 9,01) M = 68,33 (SD = 14,04) U = 235,5 0,38 Range: 48–104 Range: 48–83 Range: 53–104 Normal 33,33% (N = 14) 29,63% (N = 8) 40,00% (N = 6) X 2 = 0,48 0,78 Overweight 38,10% (N = 16) 40,74% (N = 11) 33,33% (N = 5) Obesity 28,57% (N = 12) 29,63% (N = 8) 26,67% (N = 4) Note : significance at p < 0,01; M = Mean; SD = Standard deviation; U = Mann-Whitney U; X 2 = Chi-squared In the intervention group, 18 patients had a prior diagnosis of symptomatic gallbladder stones (66.70%), mainly presenting with biliary colic, with an average of 1.63 previous episodes; 16 patients had jaundice at the time of diagnosis (59.25%), 10 had choluria (37.04%), and 8 had hypocholia (29.63%). The average common bile duct diameter was 9.28 mm. Five patients in the same group (18.5%) presented with cholecystitis at the time of diagnosis, with an average gallbladder wall thickness of 4.8 mm. Additionally, four patients (14.8%) presented with pancreatitis at the time of diagnosis, with an average amylase level of 1846 IU/l. Regarding the control group, 8 patients had a prior diagnosis of symptomatic gallbladder stones (53.30%). Five patients in this group had jaundice (33.33%), 4 had choluria (26.77%), and one had hypocholia (6.66%). The average common bile duct diameter was 11.50 mm. Six patients also presented with cholecystitis (40%) at the time of choledocholithiasis diagnosis, with an average gallbladder wall thickness of 3.73 mm, and three had pancreatitis (20%) with an average amylase level of 1711 IU/l. Table 2 summarizes the preoperative characteristics of both groups. Table 2. Preoperative characteristics of both groups Intervention (N = 27) Control (N = 15) Statistic p Biliary colic (N of episodes) M = 1,63 (SD = 1,69) M = 0,60 (SD = 0,83) U = 132,00 0,05 Range: 0–5 Range: 0–2 Cholecystitis 18,5% (N = 5) 40% (N = 6) X2 = 2,30 0,13 Pancreatitis 14,8% (N = 4) 20% (N = 3) X2 = 0,18 0,66 Jaundice 59,25% (N = 16) 33,33% (N = 5) X2 = 2,59 0,11 Choluria 37,04% (N = 10) 26,77% (N = 4) X2 = 0,46 0,49 Hypocholia 29,63% (N = 8) 6,66% (N = 1) X2 = 3,02 0,08 Common bile duct (mm) M = 9,3 (SD = 2,50) M = 11,5 (SD = 2,43) U = 295,50 0,014 Range: 6–13,5 Range: 9–16 TB (mg/dl) M = 4,29 (SD = 2,97) M = 4,45 (SD = 3,67) U = 189,00 0,72 Range: 0,97 − 12,49 Range: 0.55–12.66 DB (mg/dl) M = 3,47 (SD = 2,73) M = 3.40 (SD = 3,32) U = 179,0 0,53 Range: 0,58 − 10,92 Range: 0,29 − 11,64 TGP (U/I) M = 360 (SD = 188,27) M = 391 (SD = 249,17) U = 215,00 0,74 Range:104–940 Range: 25–964 TGO (U/I) M = 291 (SD = 170,78) M = 272,93 (SD = 163,83) U = 194,00 0,82 Range: 84–694 Range: 0-566 Note : significance at p < 0,01; M = Mean; SD = Standard deviation; U = Mann-Whitney U; X 2 = Chi-squared; TB = total bilirubin; DB = Direct bilirrubin In 25 patients of the "intervention group" (92.59%) and 14 of the "control group" (93.33%), the presence of bile stones was observed in ERCP. Two patients in the "intervention group" did not show negative images in ERCP, while this did happen in only one patient in the "control group". The average duration of ERCP in the "intervention group" was 29.88 minutes, while the average duration of LC in the same group was 61.11 minutes. The average total anesthesia time was 123.81 minutes. On average, oral tolerance was initiated 23 hours after the surgery. In the "control group," the average duration of ERCP was 34.66 minutes, while the average duration of LC in the same group was 77.67 minutes. The average combined anesthesia time for both procedures was 154 minutes. Oral tolerance was started on average 32 hours after both procedures. The average hospitalization time in the "intervention group" was 11 days. The average latency period between the first day of hospitalization and the intervention was 7.5 days (time range: 1–11 days). The average time from the intervention to discharge was 2.77 days (time range: 1–9 days). The average hospitalization time in the "control group" was 12.2 days. The average latency time between ERCP and LC was 34.5 days (time range: 1-223 days). In this group, ten cases had both interventions performed during the same hospitalization, and five were discharged after ERCP and readmitted for LC. Before performing LC, we conducted ultrasound controls on these five patients. The difference in the average anesthesia time between both groups was significant (p = 0.001), while the differences in the other items were not. Details of the procedures are summarized in Table 3 . Table 3 Details of procedures Intervention (N = 27) Control (N = 15) Statistic p ERCP duration (minutes) M = 29,88 (SD = 12,48) M = 34,66 (DE = 10,43) U = 265,50 0,086 Range: 8–60 Range: 20–60 LC duration (minutes) M = 61,11 (SD = 34,17) M = 77,67 (SD = 29,08) U = 273,00 0,034 Range: 25–150 Range:30–120 Total anesthesia time (minutes) M = 123,81 (SD = 43,63) M = 154 (SD = 30,60) U = 325,50 0,001 Range: 80–270 Range: 100–210 Oral tolerance (hours) M = 23 (SD = 20,73) M = 32,67 (SD = 23,79) U = 256,50 0,151 Range: 6–96 Range: 4–77 Hospitalization time (days) M = 11 (SD = 2,83) M = 12,2 (SD = 5,84) U = 192,50 0,94 Range: 6–16 Range: 5–29 Note : significance at p < 0,01; M = Mean; SD = Standard deviation; U = Mann-Whitney U; X 2 = Chi-squared Regarding complications, in the "intervention group", four patients had complications in one of the procedures. Two patients had papillary bleeding; the first had to be re-intervened endoscopically to control the bleeding using bipolar coagulation and topical adrenaline, while the second patient developed hypovolemic shock and melena, requiring resuscitation and conventional reoperation (suspected self-limited papillary bleeding). Two patients bled during LC and had to be re-intervened for hemostasis control. In the "intervention group," two cases were considered treatment failures. One of these patients experienced intestinal distension due to endoscopic insufflation, and we had to reschedule LC after that. In the other case, the stone could not be extracted either endoscopically or laparoscopically, requiring a conversion of the procedure to laparotomy. In the "control group," there were four complications: two related to the chosen therapeutic strategy and two associated with the surgical intervention. Two patients developed cholecystitis during the interval between ERCP and LC, requiring readmission 8 and 28 days after ERCP, respectively. In the second case, the patient experienced septic shock secondary to cholecystitis, necessitating clinical resuscitation and admission to the pediatric intensive care unit. One patient had bleeding from the LC and had to undergo reoperation to control bleeding from the vesicular bed. Another patient developed an infection at the umbilical port site. The complications of both groups are summarized in Table 4 . Table 4 Complications of both groups Complications of “intervention group” Patient n° Type of complication Time at diagnosis Resolution Patient n°1 Papillotomy bleeding Postoperative Re-endoscopy and hemostasis (bipolar coagulation and adrenaline) Patient n°2 Papillotomy bleeding Postoperative Laparotomy – intraluminal bleeding Patient n°3 LC bleeding Postoperative Re-laparoscopy and hemostasis Patient n°4 LC bleeding Postoperative Re-laparoscopy and hemostasis Complications of “control group” Patient n° Type of complication Time at diagnosis Resolution Patient n°1 Cholecystitis Post-ERCP Readmission at 8 days and intravenous antibiotic course – LC afterwards Patient n°2 Cholecystitis / Septic shock Post-ERCP Readmission at 28 days - intravenous antibiotic course and fluids – LC afterwards Patient n°3 LC bleeding Postoperative Re-laparoscopy + laparotomy and hemostasis Patient n°4 Surgical site infection Postoperative Intravenous antibiotic course A post-ERCP amylase control was performed on all patients, with values exceeding 300 U/l in six patients (range 327–1130). Three patients belonged to the "intervention group," and three belonged to the "control group." However, only one patient from the "control group" presented associated pain, and it was considered pancreatitis. In the remaining five cases, hyperamylasemia was detected in the laboratory analysis, and they did not experience associated abdominal pain. None of these six patients had hyperamylasemia or pancreatitis at the time of choledocholithiasis diagnosis. No patient experienced intestinal perforation during the endoscopic procedure, nor did they have bile duct injury following LC. All the patients were monitored for a minimum of one year, and check-ups were carried out every three months. At present, only two patients from the "intervention group" are still being observed as the procedure was recently performed. The remaining patients were followed up with telephone calls, and all of them were found to be asymptomatic and had not encountered any complications during this period. DISCUSSION Currently, the incidence of gallstone disease and its complications is increasing [ 1 , 5 ]. In both centers, there has been a rise in the number of annual LCs over the past few years (50% more), coinciding with an increase in the incidence of metabolic disease in pediatrics. More than half of the patients included in this study were overweight or obese. Although the prevalence of gallstone disease is higher in the adult population, the occurrence of common bile duct stones is considerably more frequent in pediatric patients (30%) than in adults (10%) [ 12 ]. In a patient presenting with symptoms of choledocholithiasis, the diagnostic algorithm begins with an abdominal ultrasound and a complete liver function panel. Additionally, all our patients underwent MRI cholangiography (CRMN), which was positive in all cases. In one of the reviewed studies, none of the studied patients had undergone CRMN [ 5 ]. In our experience, CRMN provided significant data for the choledocholithiasis diagnosis and guided the endoscopist when indicating ERCP. In the treatment of pediatric choledocholithiasis, various therapeutic strategies exist. Some include preoperative ERCP with sphincterotomy and bile stone extraction, others suggest laparoscopic or conventional ductal exploration during cholecystectomy [ 3 ], and others mention the possibility of performing post-cholecystectomy ERCP after intraoperative cholangiography (IOC) diagnoses bile duct stones. One advantage of performing IOC is that it avoids unnecessary instrumentation of the bile duct [ 3 ]. There are studies on this topic aiming to avoid unnecessary procedures, developing scores to assess the need for ERCP [ 13 ]. In our cases, more than 90% of the ERCPs in both groups were positive, extracting stones and biliary sludge in most patients. A disadvantage of routine IOC is that it requires the accurate training of the surgeon. In addition, some of the instruments required to remove stones from the bile duct may not be available in some centers. Moreover, learning the technique is necessary, and this may expose the patient to unnecessary radiation [ 6 ]. It has also been shown that performing IOC in all pediatric patients does not reduce the complication rate of LC [ 5 , 14 ]. This procedure is selectively performed in our centers and is not a common practice. In all patients, except for two patients that were mentioned as "failures", both procedures were successfully carried out in a single intervention with no major complications. It is worth noting that the distribution of cases between the two centers was even, which adds to the feasibility of the study. This contrasts with other studies where most of the cases were concentrated in a single center [ 9 ]. One of the reasons we chose to perform both procedures in a single intervention was the duration of the anesthesia; we aimed to reduce it. Although the potential adverse effects of anesthesia are not fully understood, it is believed that exposing pediatric patients to longer anesthesia time may impact their neurodevelopment. Analyzing the anesthesia times of both groups, the "intervention group" spent less time under the effects of anesthesia, which could be a benefit. A meta-analysis reported that successive exposures to general anesthesia result in a decrease in neurological functions [ 15 ]. In most of the studies that analyzed prolonged exposure to anesthesia, it is shown that a longer duration of anesthesia contributes to a higher risk of long-term neurocognitive function decrease. Furthermore, children in all age ranges (not just the youngest) may experience negative consequences. Since these results are mostly not significant, it remains to be explored whether the frequency, duration, specific anesthetic agents, or exposure at a certain age to general anesthesia leads to neurological changes and deterioration [ 15 ]. Some studies have shown that performing both procedures in a single intervention reduced the postoperative hospitalization time [ 6 ]. In our study, we found no significant differences in the hospitalization times or latency times between ERCP and LC. However, it is important to note that conducting both procedures in a single intervention or performing them sequentially during the same hospitalization may be beneficial. This approach could potentially prevent additional episodes of morbidity associated with gallstone disease. An analysis demonstrated that for every ten days of delay in treatment, the risk of subsequent presentations with a symptomatic episode increased by 5% [ 16 ]. Extrapolating this, with an average delay of 35 days, patients are subject to a 17.5% risk of reappearing with potentially serious complications. Two patients in the "control group," in whom LC was deferred for a second hospitalization, were readmitted earlier than expected, presenting with acute cholecystitis. Some studies have analyzed the costs of hospitalization and interventions in patients undergoing these procedures (CRMN, IOC, ERCP, LC), suggesting that performing both techniques in a single intervention is less expensive [ 5 , 7 ]. In our case, both participating centers belong to the Argentine public health system, making cost analysis difficult; however, we could interpret that by reducing hospitalization time, operating room time, and fewer anesthesia inductions, the expenditure for public health would decrease. Regarding ERCP complications, acute pancreatitis (3.5%), cholecystitis or cholangitis (1.4%), bleeding from the sphincterotomy site (1.3%), and perforation (0.6%) are mentioned [ 17 ]. Complication rates of ERCP in pediatric patients are not well established, with some studies reporting rates higher than 10%. However, there is no record of serious complications [ 18 ]. Post-sphincterotomy bleeding can be diagnosed intraoperatively or postoperatively. In our study, both cases occurred in the intervention group postoperatively. This complication was not present in the control group. Post-ERCP pancreatitis is defined as an amylase increase at least 3 times the upper limit associated with typical pancreatitis pain [ 19 ]. In our patients, three patients in the "intervention group" and three in the "control group" had post-ERCP hyperamylasemia, with only one experiencing abdominal pain, so it was considered pancreatitis. Interestingly, none of the patients who had pancreatitis at the time of choledocholithiasis diagnosis (4 in the intervention group and 3 in the control group) had post-ERCP hyperamylasemia. Regarding complications of LC in pediatrics, we consider bile duct injury (0.4%), intraoperative or postoperative bleeding (0.9%), and bile leak (2.4%) as the main ones, resulting in an overall complication rate of 3.4% [ 20 ]. In our study, both groups experienced bleeding that had to be subsequently controlled (requiring reoperation). We believe that this variable is inherent to the LC method and can occur regardless of whether it was performed in one or two interventions. Complications in both groups were not as severe as some reported in adult population studies [ 21 ]. However, it is essential to note that some complications can impair the quality of life of our patients. Therefore, none of the two procedures should be underestimated. The main limitation of this study is the difficulty in coordinating the presence of the surgeon and the endoscopist in a scheduled operating room. These limitations have already been described in other works [ 9 ]. Another disadvantage of this study is the number of patients included in both groups, even though two centers participated in this investigation. Lastly, we believe that a prospective study should be designed in the future, one that can randomize these patients into two groups to analyze more data that can contribute to performing both procedures in a single intervention. CONCLUSION The performance of ERCP and LC in a single intervention is feasible and does not pose significant risks in the pediatric population. We believe that this strategy offers advantages over other therapeutic alternatives. Additionally, the potential to reduce the overall anesthesia time to which the patient is exposed and the definitive resolution of biliary lithiasis could be crucial factors to consider when choosing this approach. We consider this prospective study to provide valuable insights and experience for safely conducting both procedures in the pediatric population. Abbreviations ERCP: endoscopic retrograde cholangiopancreatography LC: laparoscopic cholecystectomy MRCP: magnetic resonance cholangiopancreatography IOCG: intraoperative cholangiography Declarations Compliance with ethical standards Conflict of interest : The authors have no relevant financial or non-financial interests to disclose. Funding: The authors did not receive support from any organization for the submitted work. Informed consent: Informed consent was obtained from all individual participants included in the study or their legal guardians. Author contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Santángelo Agustina, Scarpin Antonella, Imaz Francisco, Vargas Raul, Cardozo Leandro and Darrigran Santiago. The first draft of the manuscript was written by Agustina Santángelo and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Mehta S, Lopez ME, Chumpitazi BP, Mazziotti M V., Brandt ML, Fishman DS. Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease. Pediatrics . 2012;129(1). doi:10.1542/peds.2011-0579 Pogorelic Z, Lovric M, Jukic M, Perko Z. The laparoscopic cholecystectomy and common bile duct exploration: a single-step treatment of pediatric cholelithiasis and choledocholithiasis. Children . 2022. doi:10.1007/BF00590952 Hill SJ, Wulkan ML, Parker PM, Jones TK, Heiss KF, Clifton MS. Management of the pediatric patient with choledocholithiasis in an era of advanced minimally invasive techniques. 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Sarrami M, Ridley W, Nightingale S, Wright T, Kumar R. Adolescent gallstones—need for early intervention in symptomatic idiopathic gallstones. Pediatr Surg Int . 2019;35(5):569-574. doi:10.1007/s00383-019-04461-w Usatin D, Fernandes M, Allen IE, Perito ER, Ostroff J, Heyman MB. Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-Analysis. J Pediatr . 2016;179:160-165.e3. doi:10.1016/j.jpeds.2016.08.046 Gaied I, Ali M, Shehata A, Hassan A. Concomitant ERCP and laparoscopic cholecystectomy for management of gallstones complicated by obstructive jaundice versus two sessions procedure comparative study, Minia university hospital experience. Minia J Med Res . 2023;0(0):0-0. doi:10.21608/mjmr.2023.182178.1250 Tryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: Pathophysiology, early identification and risk stratification. Adv Clin Exp Med . 2018;27(1):143-148. doi:10.17219/acem/66773 Mattson A, Sinha A, Njere I, Borkar N, Sinha CK. Laparoscopic cholecystectomy in children: A systematic review and meta-analysis. Surgeon . 2023;21(3):e133-e141. doi:10.1016/j.surge.2022.09.003 Bansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: A randomized con. Surg Endosc . 2014;28(3):875-885. doi:10.1007/s00464-013-3237-4 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4016988","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276551468,"identity":"f8426b9b-196a-4760-9d8a-bd9a2954bf3c","order_by":0,"name":"Agustina Santangelo","email":"data:image/png;base64,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","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":true,"prefix":"","firstName":"Agustina","middleName":"","lastName":"Santangelo","suffix":""},{"id":276551469,"identity":"052f1e46-95b7-410c-919d-5c28ce54fd58","order_by":1,"name":"Antonella Scarpin","email":"","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":false,"prefix":"","firstName":"Antonella","middleName":"","lastName":"Scarpin","suffix":""},{"id":276551470,"identity":"68ed7642-df27-44b8-bbdd-dafce3818d17","order_by":2,"name":"Francisco Imaz","email":"","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"","lastName":"Imaz","suffix":""},{"id":276551471,"identity":"66b6fe81-8c01-495e-9a41-ecd5a15414d9","order_by":3,"name":"Paula Luján Marino","email":"","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":false,"prefix":"","firstName":"Paula","middleName":"Luján","lastName":"Marino","suffix":""},{"id":276551472,"identity":"e90dd024-6908-4842-a228-afc5cc01f12f","order_by":4,"name":"Raúl Eduardo Vargas","email":"","orcid":"","institution":"Hospital del Niño Prof. Dr. Ramon Exeni","correspondingAuthor":false,"prefix":"","firstName":"Raúl","middleName":"Eduardo","lastName":"Vargas","suffix":""},{"id":276551473,"identity":"2487be5c-6041-4833-832e-572a1e7c3559","order_by":5,"name":"Leandro Alfredo Cardozo Bidart","email":"","orcid":"","institution":"Hospital del Niño Prof. Dr. Ramon Exeni","correspondingAuthor":false,"prefix":"","firstName":"Leandro","middleName":"Alfredo Cardozo","lastName":"Bidart","suffix":""},{"id":276551474,"identity":"5a29f5b0-2960-47db-9dab-446d8e46f213","order_by":6,"name":"Santiago Darrigran","email":"","orcid":"","institution":"Hospital del Niño Prof. Dr. Ramon Exeni","correspondingAuthor":false,"prefix":"","firstName":"Santiago","middleName":"","lastName":"Darrigran","suffix":""},{"id":276551475,"identity":"1187c3cf-1d76-40fc-827e-1b6bc4483b68","order_by":7,"name":"Maria Alexandra Macias","email":"","orcid":"","institution":"Hospital del Niño Prof. Dr. Ramon Exeni","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Alexandra","lastName":"Macias","suffix":""},{"id":276551476,"identity":"6f5a9097-25f4-4bf7-a931-c532459823f9","order_by":8,"name":"Juan Carlos Sanchez de Loria","email":"","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"Carlos Sanchez","lastName":"de Loria","suffix":""},{"id":276551477,"identity":"30a3faad-6d7f-4d99-a619-38ce586dcc7f","order_by":9,"name":"Pablo Ricardo Volonte","email":"","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":false,"prefix":"","firstName":"Pablo","middleName":"Ricardo","lastName":"Volonte","suffix":""},{"id":276551478,"identity":"e7191f81-f479-4554-bf09-6c7dbe132620","order_by":10,"name":"Fabian Omar Salgueiro","email":"","orcid":"","institution":"Hospital General de Niños Ricardo Gutierrez","correspondingAuthor":false,"prefix":"","firstName":"Fabian","middleName":"Omar","lastName":"Salgueiro","suffix":""}],"badges":[],"createdAt":"2024-03-05 12:14:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4016988/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4016988/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54256766,"identity":"67148dc9-31bb-4295-90c4-e64b16245073","added_by":"auto","created_at":"2024-04-08 01:37:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":336128,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4016988/v1/26e8040c-89a0-49b4-aabd-662cba7b2cdc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eConcurrent Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: a Safe Strategy in Pediatric Patients\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGallbladder stones have become an established pathology in the pediatric population, with their incidence continually rising over the last 20 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Traditionally, their etiology was associated with prematurity, the use of parenteral nutrition, and hemolytic diseases. Currently, like adults, the association with metabolic syndrome and obesity is evident [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Correspondingly, complications of gallbladder stones, such as acute cholecystitis, acute pancreatitis, and choledocholithiasis, have also shown an increased incidence recently [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe standard treatment for choledocholithiasis, described in both adults and children, involves performing endoscopic retrograde cholangiopancreatography (ERCP) initially, with sphincterotomy and extraction of bile stones, followed by delayed laparoscopic cholecystectomy (LC). Some centers schedule LC 48 to 72 hours after ERCP, while others postpone it until a second hospitalization. Other therapeutic alternatives suggest intraoperative cholangiography (IOC) during LC, with exploration and instrumentation of the bile duct, and eventual postoperative ERCP [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Less frequently, a simultaneous laparoscopic and endoscopic procedure known as Rendezvous can be performed [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese therapeutic strategies subject pediatric patients to two distinct anesthesia and surgical procedures, which could be detrimental given the inherent complications of each. Moreover, this approach leads to additional hospitalization expenses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and raises the possibility of complications related to gallstone disease such as pancreatitis, cholecystitis, and recurrence of choledocholithiasis.\u003c/p\u003e \u003cp\u003eRecently, some studies in the adult [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and pediatric [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] populations were published in which both procedures were performed in a single anesthesia session.\u003c/p\u003e \u003cp\u003eThis study aims to demonstrate that performing ERCP and subsequent LC in a single anesthesia session is safe in pediatric patients diagnosed with choledocholithiasis. It assesses immediate and intermediate complications as the primary outcome and analyses total anesthesia and hospitalization times as secondary outcomes.\u003c/p\u003e"},{"header":"DESIGN AND METHODS","content":"\u003cp\u003eThis study employed a non-randomized prospective cohort design, including patients from January 1, 2020, to June 1, 2023. It was conducted at two centers: Hospital de Ni\u0026ntilde;os Ricardo Guti\u0026eacute;rrez (CABA, Argentina) and Hospital del Ni\u0026ntilde;o Prof. Dr. Ramon Exeni (San Justo, Buenos Aires, Argentina).\u003c/p\u003e \u003cp\u003ePatients under 18 years with a diagnosis of symptomatic choledocholithiasis, showing biliary tract dilation as evidenced by ultrasonography (extrahepatic bile duct\u0026thinsp;\u0026ge;\u0026thinsp;6 mm) and confirmed by magnetic resonance cholangiopancreatography (MRCP), were included in this study. The patients were divided into two groups: the first group consisted of patients who underwent ERCP and LC during the same anesthesia session (\"intervention group\"). The second group comprised patients who underwent ERCP and LC in two separate sessions (\"control group\").\u003c/p\u003e \u003cp\u003eThe assignment of patients to their respective groups was based on the availability of the surgeon and endoscopist, who was not a permanent staff member at either hospital. If all conditions to perform the procedures simultaneously were met, the patient was assigned to the \"intervention group\". However, if conditions were not met, the patient underwent two separate sessions and was part of the \"control group\". Furthermore, patients who were diagnosed with cholecystitis or pancreatitis at the time of choledocholithiasis diagnosis were also included in this cohort. All patients provided informed consent.\u003c/p\u003e \u003cp\u003eVariables considered for this study included demographic and clinical data before the procedure, intervention details (ERCP and cholecystectomy times, total anesthesia time, ERCP outcomes), and postoperative data.\u003c/p\u003e \u003cp\u003eThe intervention was considered \"successful\" when both procedures could be performed in a single session. It was considered a \"failure\" when either the endoscopic procedure or the laparoscopic cholecystectomy could not be completed. Regarding secondary objectives, the total anesthesia time for the \"control group\" was calculated by adding the minutes for each intervention (ERCP anesthesia time\u0026thinsp;+\u0026thinsp;LC anesthesia time).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS Statistics-25 software (IBM Statistics for Windows). The Shapiro-Wilk test was applied to assess the data distribution. Results indicated that the data did not follow a normal distribution (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Considering the data distribution and the sample sizes of the clinical group and control group, non-parametric statistics were chosen to study the differences between the groups. The Mann-Whitney U test, a non-parametric statistic, was employed to examine differences in total anesthesia times and times until oral tolerance between the groups. In all cases, p-values less than 0.01 were considered significant.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eTechnical details of the procedures\u003c/h2\u003e \u003cp\u003eAll patients underwent general anesthesia with endotracheal intubation and received prophylactic antibiotic therapy with intravenous ampicillin-sulbactam (150 mg/kg/day) in a single dose.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEndoscopic procedure:\u003c/h2\u003e \u003cp\u003ePatients were positioned in the left lateral decubitus position. An Olympus duodenoscope with a 4.2 working channel was used to access the second part of the duodenum for papillotomy and cannulation with a hydrophilic guide. An iodinated contrast medium was injected (cholangiography) to map the biliary tract and identify any stones and their characteristics. The method for stone extraction varied based on the type, size, and quantity, using either a Dormia basket or a stone extraction balloon. All procedures were performed by the same endoscopic surgeon, who was responsible for evaluating and executing the procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure:\u003c/h2\u003e \u003cp\u003ePatients were placed in the dorsal decubitus position. Following the American technique, standard LC was performed with safety parameters according to Strasberg's criteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], using four ports (one umbilical for the optic, one epigastric, and two in the right flank). All patients were operated on by pediatric surgery residents and staff surgeons.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study comprised 42 patients: 27 in the \u0026ldquo;intervention group\u0026rdquo; and 15 in the \u0026ldquo;control group\u0026rdquo;. Among them, 25 patients were treated at Hospital de Ni\u0026ntilde;os Ricardo Guti\u0026eacute;rrez, while the remaining 17 received treatment at Hospital del Ni\u0026ntilde;o \u0026ldquo;Prof. Dr. Ram\u0026oacute;n Exeni\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe groups were similar in terms of age and gender. Most patients were overweight or obese at the time of the study: 38.09% overweight and 28.57% obese, based on z-scores and percentiles determined by the \u003cem\u003eSociedad Argentina de Pediatr\u0026iacute;a\u003c/em\u003e (SAP) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Most patients were categorized as ASA II in the anesthesia risk stratification. Demographic data for both groups is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;13,88 (SD\u0026thinsp;=\u0026thinsp;1,89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;13,44\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;1,80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;14,66\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;1,83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;289,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange: 10\u0026ndash;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange: 10\u0026ndash;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRange: 10\u0026ndash;17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFeminine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61,90% (N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70,37% (N\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46,67% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2,29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMasculine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.10% (N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29,63% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.33% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eWeight (Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;65,21\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;11,16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;63,48\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;9,01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;68,33\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;14,04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;235,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange: 48\u0026ndash;104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange: 48\u0026ndash;83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRange:\u003c/p\u003e \u003cp\u003e53\u0026ndash;104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33,33% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29,63% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40,00% (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0,48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0,78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOverweight\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38,10% (N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40,74% (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33,33% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eObesity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28,57% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29,63% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26,67% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0,01; M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard deviation; U\u0026thinsp;=\u0026thinsp;Mann-Whitney U; X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;Chi-squared\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the intervention group, 18 patients had a prior diagnosis of symptomatic gallbladder stones (66.70%), mainly presenting with biliary colic, with an average of 1.63 previous episodes; 16 patients had jaundice at the time of diagnosis (59.25%), 10 had choluria (37.04%), and 8 had hypocholia (29.63%). The average common bile duct diameter was 9.28 mm. Five patients in the same group (18.5%) presented with cholecystitis at the time of diagnosis, with an average gallbladder wall thickness of 4.8 mm. Additionally, four patients (14.8%) presented with pancreatitis at the time of diagnosis, with an average amylase level of 1846 IU/l.\u003c/p\u003e \u003cp\u003eRegarding the control group, 8 patients had a prior diagnosis of symptomatic gallbladder stones (53.30%). Five patients in this group had jaundice (33.33%), 4 had choluria (26.77%), and one had hypocholia (6.66%). The average common bile duct diameter was 11.50 mm. Six patients also presented with cholecystitis (40%) at the time of choledocholithiasis diagnosis, with an average gallbladder wall thickness of 3.73 mm, and three had pancreatitis (20%) with an average amylase level of 1711 IU/l. \u003cem\u003eTable\u0026nbsp;2\u003c/em\u003e summarizes the preoperative characteristics of both groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;2. Preoperative characteristics of both groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBiliary colic (N of episodes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1,63\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;1,69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;0,60\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;0,83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;132,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRange: 0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eRange: 0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholecystitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e18,5% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e40% (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX2\u0026thinsp;=\u0026thinsp;2,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e14,8% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e20% (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX2\u0026thinsp;=\u0026thinsp;0,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e59,25% (N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e33,33% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX2\u0026thinsp;=\u0026thinsp;2,59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e37,04% (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e26,77% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX2\u0026thinsp;=\u0026thinsp;0,46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypocholia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e29,63% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e6,66% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX2\u0026thinsp;=\u0026thinsp;3,02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0,08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCommon bile duct (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;9,3\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;2,50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;11,5\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;2,43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;295,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRange: 6\u0026ndash;13,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eRange: 9\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTB (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;4,29\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;2,97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;4,45\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;3,67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;189,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRange: 0,97\u0026thinsp;\u0026minus;\u0026thinsp;12,49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eRange: 0.55\u0026ndash;12.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDB (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;3,47\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;2,73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;3.40\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;3,32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;179,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRange: 0,58\u0026thinsp;\u0026minus;\u0026thinsp;10,92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eRange: 0,29\u0026thinsp;\u0026minus;\u0026thinsp;11,64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTGP (U/I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;360\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;188,27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;391\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;249,17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;215,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRange:104\u0026ndash;940\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eRange: 25\u0026ndash;964\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTGO (U/I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;291\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;170,78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;272,93\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;163,83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;194,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eRange: 84\u0026ndash;694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eRange: 0-566\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0,01; M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard deviation; U\u0026thinsp;=\u0026thinsp;Mann-Whitney U; X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;Chi-squared; TB\u0026thinsp;=\u0026thinsp;total bilirubin; DB\u0026thinsp;=\u0026thinsp;Direct bilirrubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn 25 patients of the \"intervention group\" (92.59%) and 14 of the \"control group\" (93.33%), the presence of bile stones was observed in ERCP. Two patients in the \"intervention group\" did not show negative images in ERCP, while this did happen in only one patient in the \"control group\".\u003c/p\u003e \u003cp\u003eThe average duration of ERCP in the \"intervention group\" was 29.88 minutes, while the average duration of LC in the same group was 61.11 minutes. The average total anesthesia time was 123.81 minutes. On average, oral tolerance was initiated 23 hours after the surgery.\u003c/p\u003e \u003cp\u003eIn the \"control group,\" the average duration of ERCP was 34.66 minutes, while the average duration of LC in the same group was 77.67 minutes. The average combined anesthesia time for both procedures was 154 minutes. Oral tolerance was started on average 32 hours after both procedures.\u003c/p\u003e \u003cp\u003eThe average hospitalization time in the \"intervention group\" was 11 days. The average latency period between the first day of hospitalization and the intervention was 7.5 days (time range: 1\u0026ndash;11 days). The average time from the intervention to discharge was 2.77 days (time range: 1\u0026ndash;9 days).\u003c/p\u003e \u003cp\u003eThe average hospitalization time in the \"control group\" was 12.2 days. The average latency time between ERCP and LC was 34.5 days (time range: 1-223 days). In this group, ten cases had both interventions performed during the same hospitalization, and five were discharged after ERCP and readmitted for LC. Before performing LC, we conducted ultrasound controls on these five patients.\u003c/p\u003e \u003cp\u003eThe difference in the average anesthesia time between both groups was significant (p\u0026thinsp;=\u0026thinsp;0.001), while the differences in the other items were not. Details of the procedures are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of procedures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eERCP duration (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;29,88\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;12,48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;34,66\u003c/p\u003e \u003cp\u003e(DE\u0026thinsp;=\u0026thinsp;10,43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;265,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange: 8\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange: 20\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLC duration (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;61,11\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;34,17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;77,67\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;29,08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;273,00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange: 25\u0026ndash;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange:30\u0026ndash;120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal anesthesia time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;123,81\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;43,63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;154\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;30,60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;325,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange: 80\u0026ndash;270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange: 100\u0026ndash;210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOral tolerance (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;23\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;20,73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;32,67\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;23,79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;256,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange: 6\u0026ndash;96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange: 4\u0026ndash;77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHospitalization time (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;2,83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;12,2\u003c/p\u003e \u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;5,84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;192,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange: 6\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eRange: 5\u0026ndash;29\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0,01; M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard deviation; U\u0026thinsp;=\u0026thinsp;Mann-Whitney U; X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;Chi-squared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding complications, in the \"intervention group\", four patients had complications in one of the procedures. Two patients had papillary bleeding; the first had to be re-intervened endoscopically to control the bleeding using bipolar coagulation and topical adrenaline, while the second patient developed hypovolemic shock and melena, requiring resuscitation and conventional reoperation (suspected self-limited papillary bleeding). Two patients bled during LC and had to be re-intervened for hemostasis control.\u003c/p\u003e \u003cp\u003eIn the \"intervention group,\" two cases were considered treatment failures. One of these patients experienced intestinal distension due to endoscopic insufflation, and we had to reschedule LC after that. In the other case, the stone could not be extracted either endoscopically or laparoscopically, requiring a conversion of the procedure to laparotomy.\u003c/p\u003e \u003cp\u003eIn the \"control group,\" there were four complications: two related to the chosen therapeutic strategy and two associated with the surgical intervention. Two patients developed cholecystitis during the interval between ERCP and LC, requiring readmission 8 and 28 days after ERCP, respectively. In the second case, the patient experienced septic shock secondary to cholecystitis, necessitating clinical resuscitation and admission to the pediatric intensive care unit. One patient had bleeding from the LC and had to undergo reoperation to control bleeding from the vesicular bed. Another patient developed an infection at the umbilical port site. The complications of both groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications of both groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eComplications of \u0026ldquo;intervention group\u0026rdquo;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime at diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResolution\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePapillotomy bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRe-endoscopy and hemostasis (bipolar coagulation and adrenaline)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePapillotomy bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparotomy \u0026ndash; intraluminal bleeding\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLC bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRe-laparoscopy and hemostasis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLC bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRe-laparoscopy and hemostasis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eComplications of \u0026ldquo;control group\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime at diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResolution\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholecystitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-ERCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReadmission at 8 days and intravenous antibiotic course \u0026ndash; LC afterwards\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholecystitis / Septic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-ERCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReadmission at 28 days - intravenous antibiotic course and fluids \u0026ndash; LC afterwards\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLC bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRe-laparoscopy\u0026thinsp;+\u0026thinsp;laparotomy and hemostasis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient n\u0026deg;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntravenous antibiotic course\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA post-ERCP amylase control was performed on all patients, with values exceeding 300 U/l in six patients (range 327\u0026ndash;1130). Three patients belonged to the \"intervention group,\" and three belonged to the \"control group.\" However, only one patient from the \"control group\" presented associated pain, and it was considered pancreatitis. In the remaining five cases, hyperamylasemia was detected in the laboratory analysis, and they did not experience associated abdominal pain. None of these six patients had hyperamylasemia or pancreatitis at the time of choledocholithiasis diagnosis. No patient experienced intestinal perforation during the endoscopic procedure, nor did they have bile duct injury following LC.\u003c/p\u003e \u003cp\u003eAll the patients were monitored for a minimum of one year, and check-ups were carried out every three months. At present, only two patients from the \"intervention group\" are still being observed as the procedure was recently performed. The remaining patients were followed up with telephone calls, and all of them were found to be asymptomatic and had not encountered any complications during this period.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCurrently, the incidence of gallstone disease and its complications is increasing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In both centers, there has been a rise in the number of annual LCs over the past few years (50% more), coinciding with an increase in the incidence of metabolic disease in pediatrics. More than half of the patients included in this study were overweight or obese. Although the prevalence of gallstone disease is higher in the adult population, the occurrence of common bile duct stones is considerably more frequent in pediatric patients (30%) than in adults (10%) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a patient presenting with symptoms of choledocholithiasis, the diagnostic algorithm begins with an abdominal ultrasound and a complete liver function panel. Additionally, all our patients underwent MRI cholangiography (CRMN), which was positive in all cases. In one of the reviewed studies, none of the studied patients had undergone CRMN [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our experience, CRMN provided significant data for the choledocholithiasis diagnosis and guided the endoscopist when indicating ERCP.\u003c/p\u003e \u003cp\u003eIn the treatment of pediatric choledocholithiasis, various therapeutic strategies exist. Some include preoperative ERCP with sphincterotomy and bile stone extraction, others suggest laparoscopic or conventional ductal exploration during cholecystectomy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and others mention the possibility of performing post-cholecystectomy ERCP after intraoperative cholangiography (IOC) diagnoses bile duct stones.\u003c/p\u003e \u003cp\u003eOne advantage of performing IOC is that it avoids unnecessary instrumentation of the bile duct [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There are studies on this topic aiming to avoid unnecessary procedures, developing scores to assess the need for ERCP [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our cases, more than 90% of the ERCPs in both groups were positive, extracting stones and biliary sludge in most patients.\u003c/p\u003e \u003cp\u003eA disadvantage of routine IOC is that it requires the accurate training of the surgeon. In addition, some of the instruments required to remove stones from the bile duct may not be available in some centers. Moreover, learning the technique is necessary, and this may expose the patient to unnecessary radiation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It has also been shown that performing IOC in all pediatric patients does not reduce the complication rate of LC [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This procedure is selectively performed in our centers and is not a common practice.\u003c/p\u003e \u003cp\u003eIn all patients, except for two patients that were mentioned as \"failures\", both procedures were successfully carried out in a single intervention with no major complications. It is worth noting that the distribution of cases between the two centers was even, which adds to the feasibility of the study. This contrasts with other studies where most of the cases were concentrated in a single center [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the reasons we chose to perform both procedures in a single intervention was the duration of the anesthesia; we aimed to reduce it. Although the potential adverse effects of anesthesia are not fully understood, it is believed that exposing pediatric patients to longer anesthesia time may impact their neurodevelopment. Analyzing the anesthesia times of both groups, the \"intervention group\" spent less time under the effects of anesthesia, which could be a benefit.\u003c/p\u003e \u003cp\u003eA meta-analysis reported that successive exposures to general anesthesia result in a decrease in neurological functions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In most of the studies that analyzed prolonged exposure to anesthesia, it is shown that a longer duration of anesthesia contributes to a higher risk of long-term neurocognitive function decrease. Furthermore, children in all age ranges (not just the youngest) may experience negative consequences. Since these results are mostly not significant, it remains to be explored whether the frequency, duration, specific anesthetic agents, or exposure at a certain age to general anesthesia leads to neurological changes and deterioration [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies have shown that performing both procedures in a single intervention reduced the postoperative hospitalization time [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our study, we found no significant differences in the hospitalization times or latency times between ERCP and LC. However, it is important to note that conducting both procedures in a single intervention or performing them sequentially during the same hospitalization may be beneficial. This approach could potentially prevent additional episodes of morbidity associated with gallstone disease.\u003c/p\u003e \u003cp\u003eAn analysis demonstrated that for every ten days of delay in treatment, the risk of subsequent presentations with a symptomatic episode increased by 5% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Extrapolating this, with an average delay of 35 days, patients are subject to a 17.5% risk of reappearing with potentially serious complications. Two patients in the \"control group,\" in whom LC was deferred for a second hospitalization, were readmitted earlier than expected, presenting with acute cholecystitis.\u003c/p\u003e \u003cp\u003eSome studies have analyzed the costs of hospitalization and interventions in patients undergoing these procedures (CRMN, IOC, ERCP, LC), suggesting that performing both techniques in a single intervention is less expensive [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our case, both participating centers belong to the Argentine public health system, making cost analysis difficult; however, we could interpret that by reducing hospitalization time, operating room time, and fewer anesthesia inductions, the expenditure for public health would decrease.\u003c/p\u003e \u003cp\u003eRegarding ERCP complications, acute pancreatitis (3.5%), cholecystitis or cholangitis (1.4%), bleeding from the sphincterotomy site (1.3%), and perforation (0.6%) are mentioned [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Complication rates of ERCP in pediatric patients are not well established, with some studies reporting rates higher than 10%. However, there is no record of serious complications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Post-sphincterotomy bleeding can be diagnosed intraoperatively or postoperatively. In our study, both cases occurred in the intervention group postoperatively. This complication was not present in the control group.\u003c/p\u003e \u003cp\u003ePost-ERCP pancreatitis is defined as an amylase increase at least 3 times the upper limit associated with typical pancreatitis pain [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our patients, three patients in the \"intervention group\" and three in the \"control group\" had post-ERCP hyperamylasemia, with only one experiencing abdominal pain, so it was considered pancreatitis. Interestingly, none of the patients who had pancreatitis at the time of choledocholithiasis diagnosis (4 in the intervention group and 3 in the control group) had post-ERCP hyperamylasemia.\u003c/p\u003e \u003cp\u003eRegarding complications of LC in pediatrics, we consider bile duct injury (0.4%), intraoperative or postoperative bleeding (0.9%), and bile leak (2.4%) as the main ones, resulting in an overall complication rate of 3.4% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our study, both groups experienced bleeding that had to be subsequently controlled (requiring reoperation). We believe that this variable is inherent to the LC method and can occur regardless of whether it was performed in one or two interventions.\u003c/p\u003e \u003cp\u003eComplications in both groups were not as severe as some reported in adult population studies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, it is essential to note that some complications can impair the quality of life of our patients. Therefore, none of the two procedures should be underestimated.\u003c/p\u003e \u003cp\u003eThe main limitation of this study is the difficulty in coordinating the presence of the surgeon and the endoscopist in a scheduled operating room. These limitations have already been described in other works [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Another disadvantage of this study is the number of patients included in both groups, even though two centers participated in this investigation. Lastly, we believe that a prospective study should be designed in the future, one that can randomize these patients into two groups to analyze more data that can contribute to performing both procedures in a single intervention.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe performance of ERCP and LC in a single intervention is feasible and does not pose significant risks in the pediatric population. We believe that this strategy offers advantages over other therapeutic alternatives. Additionally, the potential to reduce the overall anesthesia time to which the patient is exposed and the definitive resolution of biliary lithiasis could be crucial factors to consider when choosing this approach. We consider this prospective study to provide valuable insights and experience for safely conducting both procedures in the pediatric population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eERCP: endoscopic retrograde cholangiopancreatography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLC: laparoscopic cholecystectomy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRCP: magnetic resonance cholangiopancreatography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIOCG: intraoperative cholangiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study or their legal guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Santángelo Agustina, Scarpin Antonella, Imaz Francisco, Vargas Raul, Cardozo Leandro and Darrigran Santiago. The first draft of the manuscript was written by Agustina Santángelo and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMehta S, Lopez ME, Chumpitazi BP, Mazziotti M V., Brandt ML, Fishman DS. Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease. \u003cem\u003ePediatrics\u003c/em\u003e. 2012;129(1). doi:10.1542/peds.2011-0579\u003c/li\u003e\n \u003cli\u003ePogorelic Z, Lovric M, Jukic M, Perko Z. The laparoscopic cholecystectomy and common bile duct exploration: a single-step treatment of pediatric cholelithiasis and choledocholithiasis. \u003cem\u003eChildren\u003c/em\u003e. 2022. doi:10.1007/BF00590952\u003c/li\u003e\n \u003cli\u003eHill SJ, Wulkan ML, Parker PM, Jones TK, Heiss KF, Clifton MS. Management of the pediatric patient with choledocholithiasis in an era of advanced minimally invasive techniques. \u003cem\u003eJ Laparoendosc Adv Surg Tech\u003c/em\u003e. 2014;24(1):38-42. doi:10.1089/lap.2013.0306\u003c/li\u003e\n \u003cli\u003eRancan A, Andreetta M, Gaio P, et al. Rendezvous Procedure in Children with Cholecysto-Choledocholithiasis. \u003cem\u003eJ Laparoendosc Adv Surg Tech\u003c/em\u003e. 2019;29(8):1081-1084. doi:10.1089/lap.2018.0696\u003c/li\u003e\n \u003cli\u003eGee KM, Jones RE, Casson C, Barth B, Troendle D, Beres AL. More is less: The advantages of performing concurrent laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for pediatric choledocholithiasis. \u003cem\u003eJ Laparoendosc Adv Surg Tech\u003c/em\u003e. 2019;29(11):1481-1485. doi:10.1089/lap.2019.0429\u003c/li\u003e\n \u003cli\u003eJones M, Johnson M, Samourjian E, Slauch K, Ozobia N. ERCP and laparoscopic cholecystectomy in a combined (one-step) procedure: A random comparison to the standard (two-step) procedure. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2013;27(6):1907-1912. doi:10.1007/s00464-012-2647-z\u003c/li\u003e\n \u003cli\u003ePassi M, Inamdar S, Hersch D, Dowling O, Sejpal D V., Trindade AJ. Inpatient choledocholithiasis requiring ERCP and cholecystectomy: Outcomes of a combined single inpatient procedure versus separate-session procedures. \u003cem\u003eJ Gastrointest Surg\u003c/em\u003e. 2018;22(3):451-459. doi:10.1007/s11605-017-3588-6\u003c/li\u003e\n \u003cli\u003eWild JL, Younus MJ, Torres D, et al. Same-day combined endoscopic retrograde cholangiopancreatography and cholecystectomy: Achievable and minimizes costs. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. 2015;78(3):503-509. doi:10.1097/TA.0000000000000552\u003c/li\u003e\n \u003cli\u003eFishman DS, Barth B, Mazziotti M V., et al. Same Anesthesia Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: The Pediatric ERCP Database Intiative Experience. \u003cem\u003eJ Pediatr Gastroenterol Nutr\u003c/em\u003e. 2020;71(2):203-207. doi:10.1097/MPG.0000000000002722\u003c/li\u003e\n \u003cli\u003eStrasberg SM, Brunt LM. Rationale and Use of the Critical View of Safety in Laparoscopic Cholecystectomy. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 2010;211(1):132-138. doi:10.1016/j.jamcollsurg.2010.02.053\u003c/li\u003e\n \u003cli\u003eSetton D, Sosa P. Obesidad: gu\u0026iacute;as para su abordaje cl\u0026iacute;nico. Comit\u0026eacute; Nacional de Nutrici\u0026oacute;n. \u003cem\u003eSoc Argentina Pediatr\u0026iacute;a\u003c/em\u003e. 2012:1-65. https://www.sap.org.ar/uploads/consensos/obesidad-gu-iacuteas-para-su-abordaje-cl-iacutenico-2015.pdf.\u003c/li\u003e\n \u003cli\u003eFishman DS, Chumpitazi BP, Raijman I, et al. Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention. \u003cem\u003eWorld J Gastrointest Endosc\u003c/em\u003e. 2016;8(11):425. doi:10.4253/wjge.v8.i11.425\u003c/li\u003e\n \u003cli\u003eCapparelli MA, D\u0026acute;alessandro PD, Questa HA, Ayarzabal VH, Bailez MM, Barrenechea ME. Development of a risk score for choledocholithiasis in pediatric patients. \u003cem\u003ePediatr Surg Int\u003c/em\u003e. 2021;37(10):1393-1399. doi:10.1007/s00383-021-04952-9\u003c/li\u003e\n \u003cli\u003eKelley-Quon LI, Dokey A, Jen HC, Shew SB. Complications of pediatric cholecystectomy: Impact from hospital experience and use of cholangiography. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 2014;218(1):73-81. doi:10.1016/j.jamcollsurg.2013.09.018\u003c/li\u003e\n \u003cli\u003eXiao A, Feng Y, Yu S, et al. General anesthesia in children and long-term neurodevelopmental deficits : A systematic review.\u003c/li\u003e\n \u003cli\u003eSarrami M, Ridley W, Nightingale S, Wright T, Kumar R. Adolescent gallstones\u0026mdash;need for early intervention in symptomatic idiopathic gallstones. \u003cem\u003ePediatr Surg Int\u003c/em\u003e. 2019;35(5):569-574. doi:10.1007/s00383-019-04461-w\u003c/li\u003e\n \u003cli\u003eUsatin D, Fernandes M, Allen IE, Perito ER, Ostroff J, Heyman MB. Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-Analysis. \u003cem\u003eJ Pediatr\u003c/em\u003e. 2016;179:160-165.e3. doi:10.1016/j.jpeds.2016.08.046\u003c/li\u003e\n \u003cli\u003eGaied I, Ali M, Shehata A, Hassan A. Concomitant ERCP and laparoscopic cholecystectomy for management of gallstones complicated by obstructive jaundice versus two sessions procedure comparative study, Minia university hospital experience. \u003cem\u003eMinia J Med Res\u003c/em\u003e. 2023;0(0):0-0. doi:10.21608/mjmr.2023.182178.1250\u003c/li\u003e\n \u003cli\u003eTryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: Pathophysiology, early identification and risk stratification. \u003cem\u003eAdv Clin Exp Med\u003c/em\u003e. 2018;27(1):143-148. doi:10.17219/acem/66773\u003c/li\u003e\n \u003cli\u003eMattson A, Sinha A, Njere I, Borkar N, Sinha CK. Laparoscopic cholecystectomy in children: A systematic review and meta-analysis. \u003cem\u003eSurgeon\u003c/em\u003e. 2023;21(3):e133-e141. doi:10.1016/j.surge.2022.09.003\u003c/li\u003e\n \u003cli\u003eBansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: A randomized con. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2014;28(3):875-885. doi:10.1007/s00464-013-3237-4\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ERCP, Cholecystectomy, choledocholithiasis, anesthesia, pediatrics. ","lastPublishedDoi":"10.21203/rs.3.rs-4016988/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4016988/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGallbladder disease incidence in the pediatric population and its complications have been consistently increasing. The standard treatment for choledocholithiasis involves performing endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). These therapeutic methods require pediatric patients to undergo two different procedures. This study aims to demonstrate the safety of performing ERCP and LC in a single session in patients diagnosed with choledocholithiasis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign and Methods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective cohort study was conducted on patients under 18 years diagnosed with choledocholithiasis. They were divided into two groups: the \"intervention group\" underwent simultaneous ERCP and LC, while the \"control group\" underwent ERCP and LC in two separate sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study includes forty-two patients, with 27 assigned to the “intervention group” and 15 to the “control group”. The difference in the average anesthesia time between the two groups was significant (p=0.001). Two patients in the \"control group\" developed cholecystitis while awaiting LC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost patients endured both procedures without experiencing significant complications. The main goals were to reduce the total anesthesia duration and the morbidity associated with gallbladder stones. This prospective study, conducted at two centers, supports the safety of performing both procedures simultaneously in pediatric patients.\u003c/p\u003e","manuscriptTitle":"Concurrent Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: a Safe Strategy in Pediatric Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-08 10:32:02","doi":"10.21203/rs.3.rs-4016988/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8dc7137b-be42-49d5-85c9-f4d143be955b","owner":[],"postedDate":"March 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-08T01:29:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-08 10:32:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4016988","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4016988","identity":"rs-4016988","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}