Gallbladder Disease in Infants and Children

1. 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

2. Ann Surg 191:626-635, 1980

3. Biliary Disease • Gallstones • Hemolytic disease • Non-hemolytic disease • Biliary dyskinesia • Acalculous disease

4. Nonhemolytic Total parenteral nutrition Gallbladder stasis Lack of enteral feeding Ileal resection (necrotizing enterocolitis and Crohn’s disease) Biliary tract anomalies Adolescent pregnancy Oral contraceptives Hemolytic Sickle cell disease Spherocytosis Thalassemia Risk Factors for Cholelithiasis in Infants and Children

5. 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

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 disease – 0 – 14 days • Complicated disease • 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

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 • Surgeon’s experience with laparoscopic CBD exploration • Availability of an endoscopist to perform ERCP inchildren

14. 14/131 suspected choledocholithiasis J Pediatr Surg 32:1116-1119, 1997

15. Algorithm Suspected Choledocholithiasis

16. 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

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 • 2011: 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 2008

24. Cholangiography Cystic Duct Cannulation Kumar Clamp Technique

25. Kumar Clamp Technique Surg Endosc 8:927-930, 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 • Begin dissection high on gallbladder to expose triangle of Calot • 900 orientation cystic and common ducts

30. Critical View of Safety

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 • (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 18:127-130, 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 18:127-130, 2008

35. SSULS Cholecystectomy

36. SSULS Cholecystectomy More Difficult Operation

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

38. 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

39. SSULS CholecystectomyPediatrics • CH-A: 25 cases Mean op time – 73 min (30-122) Additional instrument/port 22 pts (88%) Nougues CP et al. JLAST 20:493-496, 2009 • CH-LA: 24 cases Mean op time – 97 min (65-145) Addt’l port – 2 pts (8%) Emami CN et al. Am Surg 76:1047-1049,2010

40. SSULS CholecystectomyPediatrics CMH: 24 cases Mean op time – 73 min Conversion to 4-port – 2 pts (8%) Garey CL et al J PediatrSurg 46:904-907, 2011

41. SSULS CholecystectomyPediatrics • Safe • Effective • Is it better than the 4-port technique?

42. CMH Prospective Randomized Trial • Power analysis - 60 patients (59 to date) • Primary outcome variable - operative time

43. Secondary Outcome Variables • Complications • Postoperative pain • Cosmesis • Infection rate • Operative charges

44. QUESTIONS www.cmhmis.com