1. ERCP for Pediatric Choledocholithiasis Lauren K. Toney

2. CH 15F scheduled for elective lap chole the following day, for recently diagnosed cholelithiasis (by ultrasound), presenting with 12hr RUQ pain. The pain is similar in character to her usual episodes of biliary colic (lasting 2-3h, onset 1-2h postprandial), but is unremitting, and associated with non-bloody, non-bilious emesis x 2 over the past 4hr. No fever/chills/SOB, recent illness, or inciting dietary factors. No diarrhea, stool color change, or decreased UOP. Able to tolerate PO. PMH of anemia. On MVN. Allergy to sulfa. Normal growth, devt. UTD immuniz. FH unknown (adopted). Lives at home with mom, dad, sister in Bothel. No smokers, travel, sick contacts. T 36.6 BP 105/43 HR 60 RR 20. Nontoxic. No jaundice. RUQ tender (+ Murphy’s at presentation). No rebound, guarding. Rest of examination normal.

3. CH WBC 6.8 Hgb 38.7 Hct 13.1 Plt 288 AST 1165Amy (1433) ALT 952Lip 205 (8996) AP 225T. bili 1.2 GGT 552C. bili 0.4

4. Pediatric Cholelithiasis 0.15% to 0.22% of children develop gallstones, and 11% to 13% of children with gallstone disease have CBD stones Gallstone disease risk factors in children: TPN, prematurity, use of certain medications (eg, furosemide, ceftriaxone), hemolytic disorders, and biliary tract disorders, dehydration, UTI. Gallstone disease risk factors in infants 0-6 months: idiopathic causes (36.4%), TPN (30%), abdominal surgery (30%), sepsis (15%), bronchopulmonary dysplasia (13%), hemolytic disease (5.5%), malabsorption (5.5%), necrotizing enterocolitis (5.5%), and hepatobiliary disease (3.6%). Gallstone composition in children: usually brown or black pigment stones

5. Pediatric Choledocholithiasis Most commonly secondary to cholelithiasis Primary choledocholithiasis: not discussed here.

6. ERCP

7. Treatment of (symptomatic) pediatric choledocholithiasis Remove obstruction (O) and source (S): (O + S) open/lap chole with IOCBDE (or IOERCP) (O  S) preop ERCP then lap chole (S  O) lap chole then ERCP (S only) spontaneous passage of CBD stones

8. Treatment of (symptomatic) pediatric choledocholithiasis Remove obstruction (O) and source (S): (O  S) preop ERCP then lap chole (S  O) lap chole then ERCP (S only) spontaneous passage of CBD stones

9. Remove obstruction (O) and source (S): (O  S) preop ERCP then lap chole typically restricted to gallstone pancreatitis, cholangitis: 1. high rate of complications in pediatric ERCP 2. low yield of preop ERCPs (~25% positive) (S  O) lap chole w IOC then ERCP higher postop yield (~45%) of ERCP done selectively for positive IOC (S only) spontaneous passage of CBD stones a valid primary treatment modality?

10. ERCP for pediatric choledocholithiasis: 1. What is the rate of complications in pediatric ERCP? 2. How to utilize the data on low yield of ERCP in preop (25%) and postop (45%) settings?

11. ERCP Safety Most common complications are pancreatitis, perforation, hemorrhage. (highly dependent upon defining criteria for pancreatitis). Adult complication rates - 3% to 7% for all ERCP procedures - up to 9.8% after therapeutic procedures have been reported Aliperti G. Complications related to diagnostic and therapeutic ERCP. Gastrointest Endosc Clin N Am 1996;6:379-407. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-18. Previously reported pediatric complication rates - 8% to 11.6% - 33% Fox VL, Werlin SL, Heyman MB. ERCP in children. J Pediatr Gastroenterol Nutr 2000;30 (3):335-42. Brown CW, Werlin SL,. The diagnostic and therapeutic role of ERCP in children. J Pediatr Gastroenterol Nutr 1993;17:19-23. Buckley A, Connon J. The role of ERCP in children and adolescents. Gastrointest Endosc 1990;36:369-72. ERCP in children: A surgeon’s perpsective. J Pediatr Surg 26: 733-735, 2001

12. ERCP safety: Diagnostic and therapeutic ERCP in the pediatric age group. Pediatr Surg Int. 2007 Feb; 23(2):111-6. Epub 2006 Dec 6

13. Diagnostic and therapeutic ERCP in the pediatric age group. Pediatr Surg Int. 2007 Feb;23(2):111-6. Epub 2006 Dec 6 Complications: Bleeding10.8% Pancreatitis43.2% Death00% Total54%

14. ERCP for pediatric choledocholithiasis: 1. What is the rate of complications in pediatric ERCP? ERCP is likely at least as safe as adults at centers well- trained in ERCP (~4% complication rate) 2. How to utilize the data on low yield of ERCP in preop (25%) and postop (45%) settings?

15. Low (and lower) yield of post- (and pre-) operative ERCP: Management of suspected common bile duct stones in children: role of selective IOC and ERCP. Journal of Pediatric Surgery, Vol 39 Iss 6, June 2004, Pp. 808-812

16. LC  EE  LC

17. Takehome points from Ontario Study 1. Suspicion of CBD stones based on clinical, biochemical, radiographic data is well-cited to have Sn ~ 99% (none of the 148 patients without suspected CBD stones ended up having them)

18. LC  E (128 days, r 2-2190) E  LC (12.5 days, r 0-120)

19. Takehome points from Ontario Study 1. Suspicion of CBD stones based on clinical, biochemical, radiographic data is well-cited to have Sn ~ 99%. 2. Wide range of time between procedures (LC  E and E  LC) highlights lack of consensus.

20. LC  E (128 days, r 2-2190) E  LC (12.5 days, r 0-120)

21. Takehome points from Ontario Study 1. Suspicion of CBD stones based on clinical, biochemical, radiographic data is well-cited to have Sn ~ 99%. 2. Wide range of time between procedures (LC  E and E  LC) highlights lack of consensus. 3. High rate of spontaneous stone passage (with no sequella) is demonstrated: 10/14 negative ERCPs (E  LC), 28/34 negative IOCs (LC  E).

22. LC  E (128 days, r 2-2190) E  LC (12.5 days, r 0-120) Positive ERCP’s: 3 of 14 (21.4%) Positive ERCP’s: 3 of 6 (50%)

23. Takehome points from Ontario Study 1. Suspicion of CBD stones based on clinical, biochemical, radiographic data is well-cited to have Sn ~ 99%. 2. Wide range of time between procedures (LC  E and E  LC) highlights lack of concensus. 3. High rate of spontaneous stone passage (with no sequella) is demonstrated: 10/14 negative ERCP (E  LC), 28/34 negative IOC’s (LC  E). 4. Comparison of yield of ERCP in LC  E vs. E  LC reveals the effect of IOC as a screen for unpassed CBD stones (none of the N=28 patients with negative IOCs had ERCP but all did well)

24. Takehome points from Ontario Study 1. Suspicion of CBD stones based on clinical, biochemical, radiographic data is well-cited to have Sn ~ 99%. 2. Wide range of time between procedures (LC  E and E  LC) highlights lack of concensus. 3. High rate of spontaneous stone passage (with no sequella) is demonstrated in the low positive rates of primary modality: 10/14 negative ERCP (E  LC), 28/34 negative IOC’s (LC  E). 4. Comparison of rates of positive ERCP pre- and post-LC reveals the effect of IOC as a screen for unpassed CBD stones. 5. ERCP is safe: no deaths, no complications, average followup of 4.2 years.

25. ERCP for pediatric choledocholithiasis: Conclusions 1. What is the rate of complications in pediatric ERCP? ERCP is likely at least as safe as adults at centers well-trained in ERCP (0%, 4% complication rate) 2. How to utilize the data on low yield of ERCP in preop (21.4%) and postop (50%) settings? Low yield reveals (1) effect of high rate of spontaneous stone passage, and (2) effect of IOC in LC  E as a further screen for passed stones. This, and not the safety of ERCP should be used in deciding whether to perform E  LC or LC  E

26. E  LC: safe, but potential for more neg ERCPs LC  E: most cases LC only: deserves more investigation

27. CH ERCP on HD #2 revealed passed stone Lap chole on HD #4 went well DC home 5 days after admission

28. Questions? Discussion Points? _________________________________ References 1. Choledocholithiasis in a 4-month-old infant. J Pediatr Surg. 2007 Jun;42(6):E19-21. 2. Clin Pediatr 28 (1989), pp. 294–298. 3. World J Gastroenterol. 2009 Mar 21;15(11):1353-8. 4. Diagnostic and therapeutic ERCP in children and adolescents: experience in a single institution Eur J Pediatr Surg. 2008 Aug;18(4):241-4. Epub 2008 Aug 14. 5. ERCP in children: A surgeon’s perpsective. J Pediatr Surg 26: 733-735, 2001 6. Aliperti G. Complications related to diagnostic and therapeutic endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 1996;6:379-407. 7. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-18. 8. Fox VL, Werlin SL, Heyman MB. Endoscopic retrograde cholangiopancreatography in children. J Pediatr Gastroenterol Nutr 2000;30 (3):335-42. 9. Brown CW, Werlin SL, Geenen JE, et al. The diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography in children. J Pediatr Gastroenterol Nutr 1993;17:19-23. 10. Buckley A, Connon J. The role of ERCP in children and adolescents. Gastrointest Endosc 1990;36:369-72.