Endoscopic biliary drainage as a safe and effective bridging therapy for complicated pediatric choledochal cysts

Management of choledochal cysts (CC) complicated by severe cholangitis, perforation, or pancreatitis remains challenging. Traditional external drainage carries substantial morbidity, highlighting the need for less invasive alternatives. To evaluate the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary drainage as a bridging therapy prior to definitive surgery in pediatric complicated CC. In this retrospective study, we reviewed 32 children (mean age 3.3 years; 25 girls) who underwent ERCP-guided nasobiliary or stent drainage between August 2019 and March 2025. Clinical outcomes included procedural success, complication rates, laboratory improvement, and the results of subsequent definitive surgical. A comparative analysis was also performed between patients who received ERCP drainage and those who underwent conventional external drainage for complicated CC. ERCP was performed for severe cholangitis (n = 26, 81.3 %), giant choledochal cysts (n = 3, 9.4 %), and biliary perforation (n = 3, 9.4 %). The overall technical success rate was 93.75 % (30/32). Post-drainage laboratory indices showed significant improvements in all parameters (all P < 0.05). All patients underwent successful definitive surgery after a mean interval of 16 days, with 96.7 % (29/30) completed laparoscopically or robotically without conversion. Compared with traditional drainage. Endoscopic drainage reduced conversion-to-open-surgery rate (0 % vs. 37.5 %, P = 0.006). Endoscopic biliary drainage represents a safe and effective bridging strategy for complicated pediatric CC, facilitating subsequent minimally invasive definitive surgery. It provides clear advantages over traditional external drainage in specialized centers.