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: , 1980

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

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

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

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 Acute cholecystitis Jaundice Pancreatitis

Timing of Cholecystectomy Non-complicated disease – 0 – 14 days Complicated disease 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

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: , 1997

Algorithm Suspected Choledocholithiasis

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

Disadvantage A number of ERCPs will be performed in patients that do not have CBD stones

IS ROUTINE CHOLANGIOGRAPHY NEEDED?

Cholangiography : Reasonable to perform cholangiography to become facile with technique 2011: 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 2008 Immediate Pre-op Evaluation with US Charges ($)Intraoperative Cholangiography Charges ($) Ultrasound study (including radiologist fee) minutes OR time C-Arm with radiologist fee Sterile drape for C- Arm Cholangiocatheter83.50 Contrast for cholangiogram TOTAL$307.67TOTAL$

Cholangiography Cystic Duct Cannulation Kumar Clamp Technique

Surg Endosc 8: , 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 orientation cystic and common ducts

Critical View of Safety

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 Experience Pts (12.9 yrs, 58.3 kg) Indication Symptomatic gallstones166 Biliary dyskinesia 35 Gallstone pancreatitis 7 Gallstones/splenectomy 6 Calculous cholecystitis 5 Other 4 IPEG, 2007 J Laparoendosc Adv Surg Tech 18: , 2008

CMH Experience Mean operative time77 min Cholangiograms – Intraoperatively 38  Stones9  Cleared intraop5  Cleared postop4 Preoperatively (ERCP) 17  Stones found8 Ductal injuries0 IPEG, 2007 J Laparoendosc Adv Surg Tech 18: , 2008

SSULS Cholecystectomy

More Difficult Operation

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

SSULS Cholecystectomy Adults Can be performed safely but is more challenging Longer operating times (75 – 120 min) Difficulty with triangulation of instruments Additional ports/instruments % 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

SSULS Cholecystectomy Pediatrics CH-A: 25 cases Mean op time – 73 min (30-122) Additional instrument/port 22 pts (88%) Nougues CP et al. JLAST 20: , 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: ,2010

SSULS Cholecystectomy Pediatrics CMH: 24 cases Mean op time – 73 min Conversion to 4-port – 2 pts (8%) Garey CL et al J Pediatr Surg 46: , 2011

SSULS Cholecystectomy Pediatrics Safe Effective Is it better than the 4-port technique?

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

Secondary Outcome Variables Complications Postoperative pain Cosmesis Infection rate Operative charges

QUESTIONS