Gallbladder Disease in Infants and Children George W. Holcomb III, MD, MBA Children’s Mercy Hospital Kansas City, Missouri

Biliary Disease Gallstones Biliary dyskinesia Acalculous disease Hemolytic disease Non-hemolytic disease Biliary dyskinesia Acalculous disease

Risk Factors for Cholelithiasis in Infants and Children Hemolytic Sickle cell disease Spherocytosis Thalassemia 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

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 in histological examination of many specimens

Pilot Study

Pilot Study

Complicated Cholelithiasis Acute cholecystitis Jaundice Pancreatitis

Timing of Cholecystectomy Non-complicated – 2 weeks 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

SUSPECTED CHOLEDOCHOLITHIASIS (Pre-operatively) Management Options

Management Options Pre-op ERCP, sphincterotomy, stone extraction Laparoscopic or open CBD exploration at time of cholecystectomy Post-op ERCP, sphincterotomy, stone extraction

Factors Surgeon’s experience with laparoscopic CBD exploration Availability of an endoscopist to perform ERCP in children

Algorithm Suspected Choledocholithiasis

Why? 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 2006: Most surgeons have become facile with this technique

Cholangiography To evaluate for CBD stones To define anatomy

One Surgeon’s 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 gallbladder stones, evaluate for CBD dilation or stones Cost-effective strategy

Immediate Pre-op Evaluation with US Intraoperative Cholangiography Financial analysis of preoperative ultrasonography versus intraoperative cholangiography for detection of choledocholithiasis at Children's’ Mercy Hospital, Kansas City MO Immediate Pre-op Evaluation with US Charges ($) Intraoperative Cholangiography 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 $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?

Port Placement

Stab Incision Technique 2 cannulas 2 stab incisions J Pediatr Surg 38:1837-1840, 2003

The Use of Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003

Cost Savings from Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003

Key Steps in Operation Begin dissection high on gallbladder to expose triangle of Calot

Create 90 b/w cystic duct and CBD Key Steps in Operation Create 90 b/w cystic duct and CBD

What Do I Do If I Cut the Common Bile Duct?

Options Ligate duct Repair laparoscopically Repair open wait for it to enlarge transfer to experienced biliary surgeon Repair laparoscopically Repair open interrupted sutures T – tube choledochojejunostomy at second operation

CMH Experience 2000 - 2006 224 Pts (65% female) Indication (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

CMH Experience 2000-2006 Mean operative time 77 min Cholangiogram – Preoperatively (ERCP) 17 Stones 8 Intraoperatively 38 Stones 9 Cleared intraop 5 Cleared postop 4 Postoperatively (ERCP) 2 Stones 0 Ductal injuries 0 IPEG, 2007

Laparoscopy for Splenic Conditions George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

Splenic Conditions ITP Spherocytosis Splenic cysts Wandering spleen J Pediatr Surg 28:689-692, 1993

Pre-Operative Preparation Ultrasound Often done by pediatrician, hematologist Rarely needed for splenectomy, except may be useful for extremely large spleen CT Scan – Useful in planning splenic cystectomy WinRho Bone marrow stimulant Usually used to platelet count Useful pre-operatively to platelet count in ITP pt. Immunizations –Pneumococcus (Prevnar, Pneumovax)

Patient Positioning

Patient Positioning

Personnel Positions

Laparoscopic Splenectomy ITP, spherocytosis Port placement (2) cannulas (5, 12) (2) stab (3 mm) incisions Instruments Harmonic scalpel (5 mm) Articulating stapler (12 mm)

Laparoscopic Splenectomy Operative Steps Divide spleno-colic ligament, then short gastrics Clip artery Autotransfuse pt Protects stapler malfxn

Laparoscopic Splenectomy Operative Steps Divide spleno-renal lig. Articulating stapler across hilum Bag specimen, morcellate extracorporally

Laparoscopic Splenectomy

Issues How large is too large? 28 cm. – Splenic artery ligation helpful Can divide spleen (spherocytosis) with harmonic, if necessary

Issues Postoperative platelet ct. > 500,000 Reports of splenic vein/portal vein thrombosis following splenectomy (open and laparoscopic) Baby aspirin ( 81 mg) QD for 6 mos Re-check at 3 months & 6 months

Splenic Cysts Primary Pseudocysts (secondary) epithelial lining no epithelial lining often develop after trauma

Laparoscopic Splenic Cystectomy First step is decompression of cyst

Laparoscopic Splenic Cystectomy Excise cyst as close as possible to splenic parenchyma with harmonic scalpel Coagulate lining with Argon beam coagulator ? Place omentum adjacent to exposed cyst lining

European Experience 3 European centers (Mainz, Mannheim, Hannover) 1995 - 2005 14 pts (median 8.5 yr) 10 recurrences (71%) APSA 2006

Wandering Spleen

Wandering Spleen

Laparoscopic Splenopexy J Pediatr Surg 42:E23-27, 2007

I.U. Experience 1995 - 2006 231 patients Mean age 7.7 yrs Lap splenectomy – 223 211 - total 12 - partial Lap splenic cystectomy – 6 Lap splenopexy - 2 Ann Surg, in Press

I.U. Experience 1995 – 2006 Complications Ileus - 5 Bleeding - 4 Acute chest syndrome- 5 Pneumonia - 2 Portal vein thrombosis - 1 HUS - 1 Diaphragm perforation 2 Colon injury - 1 Port site hernia - 1 Total splenectomy after partial - 1 Recurrent cyst - 1 11% overall, 22% in SCD Ann Surg, in Press

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