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Gallbladder Disease in Infants and Children

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Title: THE ACUTE SCROTUM Author: dostlie Last modified by: bjuarez Created Date: 7/29/2000 2:13:50 AM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: 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 Experience 2000-2006
  • 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.
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