1. Gallbladder Disease in Infants and Children 2010 WOFAPS 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. 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

5. 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

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 – 0 – 14 days Complicated 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 (PRE-OPERATIVELY)

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 in children

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 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 2010: 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 2007 Immediate Pre-op Evaluation with US Charges ($)Intraoperative Cholangiography Charges ($) Ultrasound study (including radiologist fee) 307.6715-minutes OR time1500.00 C-Arm with radiologist fee 365.41 Sterile drape for C- Arm 20.00 Cholangiocatheter83.50 Contrast for cholangiogram 40.00 TOTAL$307.67TOTAL$2008.91

24. Cholangiography Cystic Duct Cannulation Kumar Clamp Technique

25. 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 1.Begin dissection high on gallbladder to expose triangle of Calot

30. Key Steps in Operation 2.Create 90  b/w cystic duct and CBD

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 (# female ) (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 18:127-130, 2008

34. CMH Experience 2000-2006 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 18:127-130, 2008

35. www.cmhcenterforminimallyinvasivesurgery.com

36. References 1.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.