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Gallbladder Disease in Infants and Children

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

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Gallbladder Disease in Infants and Children

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  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

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