Gallbladder Disease in Infants and Children

2010 WOFAPS 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 with CCK stimulation

• 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 – 0 – 14 days

• Complicated• 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

(PRE-OPERATIVELY)

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 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 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

• 2010: 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 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

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

Key Steps in Operation

2. Create 90 b/w cystic duct and CBD

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 (# 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, 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

www.cmhcenterforminimallyinvasivesurgery.com

References1. 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 41:1545-1548, 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 39:813-6, 2004

3. Patel NA, Lamb JJ, Hogle NJ, Fowler DL: Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia. Am J Surg 187:209-12, 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 8:927-930, 1994.

6. Holcomb GW III, Morgan WM III, Neblett WW III, Pietsch, JB, O’Neill 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; 37:178-82.

9. Mayer EA, Collins SM: Evolving pathophysiologic models of functional gastrointestinal disorders. Gastroenterology 2002; 122:2032-48.

10. Campbell BT, Narasimhan NP, Golladay ES, Hirschl RB: Biliary dyskinesia: a potentially unrecognized cause of abdominal pain in children. Pediatr Surg Int 2004, 20:579-81, Epub 2004.

11. Shaffer E: Acalculous biliary pain: new concepts for an old entity. Dig Liver Dis 35 Suppl 3:S20-5, 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 192:196-202, 2006.

13. Taylor E, Wong C: The optimal timing of laparoscopic cholecystectomy in mild gallstone pancreatitis. Am Surg 70:971-5, 2004.