**Background:** Endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are increasingly performed in children due to technological advances, but indications differ from adults—primarily congenital malformations rather than malignancy or gallstone disease. Pediatric applications are limited by instrumentation size, operator expertise, and radiation exposure concerns. Laparoscopic common bile duct exploration (LCBDE) has been proposed as an alternative to ERCP in children. This study reports a single-center experience combining echo-endoscopy, duodenoscopy, ERCP, minimally invasive surgery (MIS), and virtual reality (VR) preoperative planning for pediatric hepatobiliary and pancreatic disorders.
**Methods:** A retrospective case series of 12 pediatric patients managed at the Department of Pediatric Surgery, Buzzi Children’s Hospital, over three years. Inclusion criteria: congenital duplication cysts of the foregut and pancreato-biliary abnormalities. Exclusion criteria: midgut/hindgut duplications and patients treated before the study period. Demographic, clinical, radiological, endoscopic, and surgical data were recorded. EUS was performed using a Pentax EG-3870UTK linear-array echoendoscope (insertion tube diameter 12.8 mm) for patients >15 kg, or EBUS (ultrasound video bronchoscope, diameter 6.3–7.4 mm) for children <15 kg. ERCP used a standard adult duodenoscope (Pentax ED34-i10T, outer diameter 11.6 mm) in patients >10 kg. MRI images were processed into 3D models using 3D Slicer v.4.11 and viewed in VR using Oculus Quest v.1 HMD. A multidisciplinary team including pediatric surgeons, pediatric radiologists, adult endoscopists, pathologists, and oncologists discussed all cases.
**Key Results:** Twelve patients (mean age 7.4 years, range 20 days–16 years; mean weight 30.3 kg, range 3.5–80 kg) were included. EUS was performed in 8 patients and successfully enabled differential diagnosis of duplication cysts and visualization of biliary tree and pancreatic anatomy. ERCP was attempted in 5 patients: completed successfully in 1 case (permitting preservation of pancreatic tissue and postponing surgery), technically unfeasible in 3 patients, and in 1 complex case (patient 12) a first failed choledochal stenting was followed by external insertion of two biliary stents, steroid therapy, and successful combined "rendez-vous" choledochal cannulation. MIS was performed in 7 patients, including LCBDE in 2 patients. LCBDE was performed as a primary procedure in 2 cases and after ERCP failure in 2 cases. Preoperative VR HMD evaluation was used in 4 complex cases (lithiasis with anatomical malformations and proliferative diseases) to visualize the biliary tree, define intrahepatic involvement, and simulate the surgical approach. In patient 5, VR HMD identified an accessory biliary branch not detected by traditional imaging. Post-operative management focused on early oral feeding and discharge, with serial ultrasounds as needed.
**Clinical Implications:** This case series highlights that pediatric EUS and ERCP are primarily indicated for congenital anomalies, especially in children under 5 years, while adolescent indications more closely resemble adult populations (e.g., choledocholithiasis). The authors report an ERCP success rate lower than the 90.7% cited in literature, with failures attributed to young age, low body weight, and anatomical challenges. They note that post-endoscopic pancreatitis occurs after ERCP in up to 12% of pediatric cases, and that LCBDE offers advantages including single-procedure definitive treatment, reduced anesthesia exposure, and avoidance of papillotomy or fluoroscopy. The authors advocate for LCBDE as the method of choice in pediatric patients when performed in specialized centers with dedicated teams. VR HMD preoperative planning improved anatomical understanding, team communication, and surgical simulation in complex malformations. The study underscores the need for dedicated pediatric instrumentation, multidisciplinary collaboration, and referral to tertiary pediatric centers for management of common bile duct pathologies in children.