Gallbladder Disease in Infants and Children

2011 ISW Meeting

George W. Holcomb III, MD, MBASurgeon-in-Chief

Children’s Mercy HospitalKansas City, Missouri

Ann Surg 191:626-635, 1980Ann Surg 191:626-635, 1980

Biliary Disease

• Gallstones• Hemolytic disease• Non-hemolytic disease

• Biliary dyskinesia

• Acalculous disease

Risk Factors for Cholelithiasis in Infants and Children

NonhemolyticNonhemolyticTotal parenteral nutrition

Gallbladder stasis

Lack of enteral feeding

Ileal resection(necrotizing enterocolitis and

Crohn’s disease)

Biliary tract anomalies

Adolescent pregnancy

Oral contraceptives

HemolyticHemolyticSickle cell diseaseSickle cell disease

SpherocytosisSpherocytosis

Thalassemia Thalassemia

Biliary Dyskinesia• Symptomatic biliary colic w/o stones

• Reduced GBEF and pain with CCK stimulation

• Has become the most common reason for cholecystectomy in many U.S. centers

• IU study – 37 pts – 71% resolution of symptoms GBEF < 15% successful resolution of

symptoms (O.R. – 8.00)

• Chronic cholecystitis seen on histological examination of many specimens

Symptoms

• Epigastric/RUQ pain

• Nausea/vomiting

• Fatty food intolerance

• Painless jaundice

• Pancreatitis

Imaging Studies

• Ultrasound

• Radionucleide gallbladder emptying study (with CCK)

• Hepatobiliary scan

Complicated Cholelithiasis

• Acutecholecystitis

• Jaundice

• Pancreatitis

Timing of Cholecystectomy

• Non-complicated disease – 0 – 14 days

• Complicated disease• Jaundice – following work-up• Cholecystitis – 2-4 days• Pancreatitis – once resolved

When to Suspect Choledocholithiasis?

• Elevated bilirubin (jaundice)

• Elevated lipase, amylase (pancreatitis)

• Dilated CBD or stone(s) in CBD on ultrasound

MANAGEMENT OF

SUSPECTED

CHOLEDOCHOLITHIASIS

Management Options

• Pre-op ERCP, sphincterotomy, stone extraction

• Laparoscopic or open CBD exploration at time of cholecystectomy

• Post-op ERCP, sphincterotomy, stone extraction (adults)

Factors

• Surgeon’s experience with laparoscopic CBD exploration

• Availability of an endoscopist to perform ERCP in children

14/131 suspected choledocholithiasis14/131 suspected choledocholithiasis

J Pediatr Surg 32:1116-1119, 1997J Pediatr Surg 32:1116-1119, 1997

Algorithm Suspected Choledocholithiasis

Why ERCP First?

• Surgeon knows at time of laparoscopic cholecystectomy whether CBD (laparoscopic or open) exploration is needed

• Potentially avoids a third anesthesia and operation

Disadvantage

A number of ERCPs will be

performed in patients that do not

have CBD stones

IS ROUTINE CHOLANGIOGRAPHY

NEEDED?

Cholangiography

• 1990-1995: Reasonable to perform cholangiography to become facile with technique

• 2011: Most surgeons have become facile with this technique

Cholangiography

• To evaluate for CBD stones

• To define anatomy

My Approach

• Reserve cholangiography for cases where anatomy is unclear

• Use ultrasound pre-operatively to define CBD involvement

Pre-operative Ultrasound

• Prior to laparoscopic cholecystectomy

• Confirm stones, evaluate for CBD dilation or stones

• Cost-effective strategy

Financial analysis of preoperative ultrasonography versus intraoperative cholangiography for detection of choledocholithiasis at

Children's’ Mercy Hospital, Kansas City MO 2008

Immediate Pre-op Evaluation with US

Charges ($)

Intraoperative Cholangiography

Charges ($)

Ultrasound study (including radiologist fee)

307.67 15-minutes OR time 1500.00

C-Arm with radiologist fee

365.41

Sterile drape for C-Arm

20.00

Cholangiocatheter 83.50

Contrast for cholangiogram

40.00

TOTAL $307.67 TOTAL $2008.91

Cholangiography

Cystic Duct Cannulation

Kumar Clamp Technique

Kumar Clamp Technique

Surg Endosc 8:927-930, 1994

Where do I place the instruments/ports for a

laparoscopic cholecystectomy?

Port Placement

Stab Incision Technique

• 2 cannulas

• 2 stab incisions

Key Steps in Operation

1. Begin dissection high on gallbladder to expose triangle of Calot

2. 900 orientation cystic and common ducts

Critical View of Safety

What Do I Do If I Cut

the Common Bile Duct?

Options

• Ligate duct • wait for it to enlarge • transfer to experienced biliary surgeon

• Repair laparoscopically

• Repair open• interrupted sutures• T – tube• choledochojejunostomy at second operation

CMH Experience2000 - 2006

• 224 Pts(12.9 yrs, 58.3 kg)

• Indication• Symptomatic gallstones

166

• Biliary dyskinesia 35

• Gallstone pancreatitis 7

• Gallstones/splenectomy 6

• Calculous cholecystitis 5

• Other 4

IPEG, 2007IPEG, 2007J Laparoendosc Adv Surg Tech 18:127-130, 2008J Laparoendosc Adv Surg Tech 18:127-130, 2008

CMH Experience2000-2006

• Mean operative time 77 min

• Cholangiograms – Intraoperatively 38

Stones 9 Cleared intraop 5 Cleared postop 4

Preoperatively (ERCP) 17 Stones found 8

• Ductal injuries 0

IPEG, 2007IPEG, 2007J Laparoendosc Adv Surg Tech 18:127-130, 2008J Laparoendosc Adv Surg Tech 18:127-130, 2008

SSULS Cholecystectomy

SSULS CholecystectomyMore Difficult Operation

SSULS Cholecystectomy

Please use this link if you experience problems viewing the video above.

SSULS CholecystectomyAdults

• Can be performed safely but is more challenging

• Longer operating times (75 – 120 min)

• Difficulty with triangulation of instruments

• Additional ports/instruments - 10-30% cases

• Sutures thru infundibulum or fundus for retraction

• Slight incidence injury CBD (0.7% vs 0.2%)

• Selected patients Relatively thin patient Non-inflamed gallbladder Intra-op cholangiogram can be difficult

SSULS CholecystectomyPediatrics

• CH-A: 25 casesMean op time – 73 min (30-122)Additional instrument/port 22 pts (88%)Nougues CP et al. JLAST 20:493-496, 2009

• CH-LA: 24 casesMean op time – 97 min (65-145)Addt’l port – 2 pts (8%)Emami CN et al. Am Surg 76:1047-1049,2010

SSULS CholecystectomyPediatrics

CMH: 24 cases

Mean op time – 73 min

Conversion to 4-port – 2 pts (8%)

Garey CL et alGarey CL et al

J Pediatr Surg 46:904-907, 2011J Pediatr Surg 46:904-907, 2011

SSULS CholecystectomyPediatrics

• Safe

• Effective

• Is it better than the 4-port technique?

CMH Prospective Randomized Trial

• Power analysis - 60 patients (59 to date)

• Primary outcome variable - operative time

Secondary Outcome Variables

• Complications

• Postoperative pain

• Cosmesis

• Infection rate

• Operative charges

www.cmhmis.com

QUESTIONS