Gallbladder Disease in Infants and Children

1
Gallbladder Disease in Infants and Children

• 2010 WOFAPS Meeting
• George W. Holcomb III, MD, MBA
• Surgeon-in-Chief
• Childrens Mercy Hospital
• Kansas City, Missouri

2
Ann Surg 191626-635, 1980
3
Biliary Disease

• Gallstones
• Hemolytic disease
• Non-hemolytic disease
• Biliary dyskinesia
• Acalculous disease

4
Risk Factors for Cholelithiasis in Infants and
Children

• Nonhemolytic
• Total parenteral nutrition
• Gallbladder stasis
• Lack of enteral feeding
• Ileal resection
• (necrotizing enterocolitis and Crohns disease)
• Biliary tract anomalies
• Adolescent pregnancy
• Oral contraceptives

• Hemolytic
• Sickle cell disease
• Spherocytosis
• Thalassemia

5
Biliary Dyskinesia

• Symptomatic biliary colic w/o stones
• Reduced GBEF with CCK stimulation
• IU study 37 pts 71 resolution of symptoms
• GBEF lt 15 successful resolution of
  symptoms (O.R. 8.00)
• Chronic cholecystitis seen on histological
  examination of many specimens

6
Symptoms

• Epigastric/RUQ pain
• Nausea/vomiting
• Fatty food intolerance
• Painless jaundice
• Pancreatitis

7
Imaging Studies

• Ultrasound
• Radionucleide gallbladder emptying study (with
  CCK)
• Hepatobiliary scan

8
Complicated Cholelithiasis

• Acute
• cholecystitis
• Jaundice
• Pancreatitis

9
Timing of Cholecystectomy

• Non-complicated 0 14 days
• Complicated
• Jaundice following work-up
• Cholecystitis 2-4 days
• Pancreatitis once resolved

10
When to Suspect Choledocholithiasis?

• Elevated bilirubin (jaundice)
• Elevated lipase, amylase (pancreatitis)
• Dilated CBD or stone(s) in CBD on ultrasound

11
MANAGEMENT OF SUSPECTED CHOLEDOCHOLITHIASIS(PRE-O
PERATIVELY)
12
Management Options

• Pre-op ERCP, sphincterotomy, stone extraction
• Laparoscopic or open CBD exploration at time of
  cholecystectomy
• Post-op ERCP, sphincterotomy, stone extraction
  (adults)

13
Factors

• Surgeons experience with laparoscopic CBD
  exploration
• Availability of an endoscopist to perform ERCP in
  children

14
14/131 suspected choledocholithiasis
J Pediatr Surg 321116-1119, 1997
15
Algorithm Suspected Choledocholithiasis
16
Why ERCP First?

• Surgeon knows at time of laparoscopic
  cholecystectomy whether CBD (laparoscopic or
  open) exploration needed
• Potentially avoids a third anesthesia and
  operation

17
Disadvantage

• A number of ERCPs will be performed in patients
  that do not have CBD stones

18
IS ROUTINE CHOLANGIOGRAPHY NEEDED?
19
Cholangiography

• 1990-1995 Reasonable to perform cholangiography
  to become facile with technique
• 2010 Most surgeons have become facile with this
  technique

20
Cholangiography

• To evaluate for CBD stones
• To define anatomy

21
My Approach

• Reserve cholangiography for cases where anatomy
  is unclear
• Use ultrasound pre-operatively to define CBD
  involvement

22
Pre-operative Ultrasound

• Prior to laparoscopic cholecystectomy
• Confirm stones, evaluate for CBD dilation or
  stones
• Cost-effective strategy

23
Financial analysis of preoperative
ultrasonography versus intraoperative
cholangiography for detection of
choledocholithiasis at Children's Mercy
Hospital, Kansas City MO 2007
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
24
Cholangiography

• Cystic Duct Cannulation
• Kumar Clamp Technique

25
Kumar Clamp Technique
Surg Endosc 8927-930, 1994
26
Where do I place the instruments/ports for a
laparoscopic cholecystectomy?
27
Port Placement
28
Stab Incision Technique

• 2 cannulas
• 2 stab incisions

29
Key Steps in Operation

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

30
Key Steps in Operation

1. Create 90? b/w cystic duct and CBD

31
What Do I Do If I Cut the Common Bile Duct?
32
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

33
CMH Experience
2000 - 2006

• 224 Pts ( female)
• (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, 2007 J Laparoendosc Adv Surg Tech
18127-130, 2008
34
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, 2007 J Laparoendosc Adv Surg Tech
18127-130, 2008
35
www.cmhcenterforminimallyinvasivesurgery.com
36
References

1. Rau B, Friesen CA, Daniel JF, Qadeer A, You-Li D,
   Roberts CC, Holcomb GW III Gallbladder wall
   inflammatory cells in pediatric paitents with
   biliary dyskinesia and cholelithiasis a pilot
   study. J Pediatr Surg 411545-1548, 2006.
2. Carney DE, Kokoska ER, Grosfeld JL, Engum SA,
   Rouse TM, West KM, Ladd A, Rescorla FJ
   Predictors of successful outcome after
   cholecystectomy for biliary dyskinesia. J Pediatr
   Surg 39813-6, 2004
3. Patel NA, Lamb JJ, Hogle NJ, Fowler DL
   Therapeutic efficacy of laparoscopic
   cholecystectomy in the treatment of biliary
   dyskinesia. Am J Surg 187209-12, 2004.
4. Holcomb GW III, Sharp KW, Neblett WW III, Morgan
   WM III, Pietsch JB Laparoscopic cholecystectomy
   in infants and children Modifications and cost
   analysis. J Pediatr Surg 29 900-904, 1994.
5. Holzman MD, Sharp K, Holcomb GW III, Frexes-Steed
   M, Richards WO An alternative technique for
   laparoscopic cholangiography. Surg Endosc
   8927-930, 1994.
6. Holcomb GW III, Morgan WM III, Neblett WW III,
   Pietsch, JB, ONeill JA Jr. Shyr Y Laparoscopic
   cholecystectomy in children Lessons learned from
   the first 100 patients. J Pediatr Surg 34
   1236-1240, 1999.
7. Newman KD, Holcomb GW III, Powell DM The
   management of choledocholithiasis in children in
   the era of laparoscopic cholecystectomy. J
   Pediatr Surg 32 1120-1123, 1997.
8. Hadigan C, Fishman SJ, Connolly LP, et al
   Stimulation with fatty meal (Lipomul) to assess
   gallbladder emptying in children with chronic
   acalculous cholecystitis. J Pediatric
   Gastroenterol Nutr 2003 37178-82.
9. Mayer EA, Collins SM Evolving pathophysiologic
   models of functional gastrointestinal disorders.
   Gastroenterology 2002 1222032-48.
10. Campbell BT, Narasimhan NP, Golladay ES, Hirschl
    RB Biliary dyskinesia a potentially
    unrecognized cause of abdominal pain in children.
    Pediatr Surg Int 2004, 20579-81, Epub 2004.
11. Shaffer E Acalculous biliary pain new concepts
    for an old entity. Dig Liver Dis 35 Suppl
    3S20-5, 2003.
12. Finan KR, Leeth RR, Whitley BM, Klapow JC, Hawn
    MT Improvement in gastrointestinal symptoms and
    quality of life after cholecystectomy. Am J Surg
    192196-202, 2006.
13. Taylor E, Wong C The optimal timing of
    laparoscopic cholecystectomy in mild gallstone
    pancreatitis. Am Surg 70971-5, 2004.