gallbladder disease in infants and children
DESCRIPTION
Gallbladder Disease in Infants and Children. 2011 ISW Meeting George W. Holcomb III, MD, MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri. Ann Surg 191:626-635, 1980. Biliary Disease. Gallstones Hemolytic disease Non-hemolytic disease Biliary dyskinesia - PowerPoint PPT PresentationTRANSCRIPT
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Gallbladder Disease in Infants and Children
2011 ISW Meeting
George W. Holcomb III, MD, MBASurgeon-in-Chief
Children’s Mercy HospitalKansas City, Missouri
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Ann Surg 191:626-635, 1980Ann Surg 191:626-635, 1980
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Biliary Disease
• Gallstones• Hemolytic disease• Non-hemolytic disease
• Biliary dyskinesia
• Acalculous disease
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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
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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
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Symptoms
• Epigastric/RUQ pain
• Nausea/vomiting
• Fatty food intolerance
• Painless jaundice
• Pancreatitis
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Imaging Studies
• Ultrasound
• Radionucleide gallbladder emptying study (with CCK)
• Hepatobiliary scan
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Complicated Cholelithiasis
• Acutecholecystitis
• Jaundice
• Pancreatitis
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Timing of Cholecystectomy
• Non-complicated disease – 0 – 14 days
• Complicated disease• Jaundice – following work-up• Cholecystitis – 2-4 days• Pancreatitis – once resolved
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When to Suspect Choledocholithiasis?
• Elevated bilirubin (jaundice)
• Elevated lipase, amylase (pancreatitis)
• Dilated CBD or stone(s) in CBD on ultrasound
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MANAGEMENT OF
SUSPECTED
CHOLEDOCHOLITHIASIS
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Management Options
• Pre-op ERCP, sphincterotomy, stone extraction
• Laparoscopic or open CBD exploration at time of cholecystectomy
• Post-op ERCP, sphincterotomy, stone extraction (adults)
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Factors
• Surgeon’s experience with laparoscopic CBD exploration
• Availability of an endoscopist to perform ERCP in children
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14/131 suspected choledocholithiasis14/131 suspected choledocholithiasis
J Pediatr Surg 32:1116-1119, 1997J Pediatr Surg 32:1116-1119, 1997
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Algorithm Suspected Choledocholithiasis
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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
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Disadvantage
A number of ERCPs will be
performed in patients that do not
have CBD stones
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IS ROUTINE CHOLANGIOGRAPHY
NEEDED?
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Cholangiography
• 1990-1995: Reasonable to perform cholangiography to become facile with technique
• 2011: Most surgeons have become facile with this technique
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Cholangiography
• To evaluate for CBD stones
• To define anatomy
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My Approach
• Reserve cholangiography for cases where anatomy is unclear
• Use ultrasound pre-operatively to define CBD involvement
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Pre-operative Ultrasound
• Prior to laparoscopic cholecystectomy
• Confirm stones, evaluate for CBD dilation or stones
• Cost-effective strategy
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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
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Cholangiography
Cystic Duct Cannulation
Kumar Clamp Technique
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Kumar Clamp Technique
Surg Endosc 8:927-930, 1994
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Where do I place the instruments/ports for a
laparoscopic cholecystectomy?
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Port Placement
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Stab Incision Technique
• 2 cannulas
• 2 stab incisions
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Key Steps in Operation
1. Begin dissection high on gallbladder to expose triangle of Calot
2. 900 orientation cystic and common ducts
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Critical View of Safety
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What Do I Do If I Cut
the Common Bile Duct?
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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
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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
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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
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SSULS Cholecystectomy
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SSULS CholecystectomyMore Difficult Operation
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SSULS Cholecystectomy
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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
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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
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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
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SSULS CholecystectomyPediatrics
• Safe
• Effective
• Is it better than the 4-port technique?
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CMH Prospective Randomized Trial
• Power analysis - 60 patients (59 to date)
• Primary outcome variable - operative time
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Secondary Outcome Variables
• Complications
• Postoperative pain
• Cosmesis
• Infection rate
• Operative charges