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

Gallbladder Disease in Infants and Children

George W. Holcomb III, MD, MBA

Children’s Mercy HospitalKansas City, Missouri

Biliary Disease

• Gallstones

• Hemolytic disease

• Non-hemolytic disease

• Biliary dyskinesia

• Acalculous disease

Risk Factors for Cholelithiasis in Infants and Children

NonhemolyticNonhemolyticTotal parenteral nutritionGallbladder stasisLack of enteral feedingIleal resection(necrotizing enterocolitis and

Crohn’s disease)

Biliary tract anomalies

Adolescent pregnancy

Oral contraceptives

HemolyticHemolyticSickle cell diseaseSickle cell disease

SpherocytosisSpherocytosis

Thalassemia Thalassemia

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 SUSPECTED CHOLEDOCHOLITHIASISCHOLEDOCHOLITHIASIS

(Pre-operatively)(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 IS ROUTINE CHOLANGIOGRAPHY CHOLANGIOGRAPHY

NEEDED?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

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

Charges ($)

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 TOTAL $2008.91

Cholangiography

Cystic Duct Cannulation

Kumar Clamp Technique

Kumar Clamp Technique

Surg Endosc 8:927-930, 1994

Where do I place the Where do I place the instruments/ports?instruments/ports?

Port Placement

Stab Incision Technique

• 2 cannulas

• 2 stab incisions

J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003

The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4

Nissen (14) 2 3

Heller Myotomy (7) 2 3

Appendectomy (102) 2 1

Meckel’s Diverticulum (2) 2 1

Pyloromyotomy (77) 1 2

Cholecystectomy (31) 2 2

Pullthrough (20) 2 1

Splenectomy (21) 2 2

Adrenalectomy (6) 2 2

UDT (15) 1 2

Varicocele (5) 1 2

Ovarian (2) 1 2

Totals (511) 714 1337

PAPS 2003PAPS 2003JPS 38:1837-1840, 2003JPS 38:1837-1840, 2003

Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) 5,880 / 2,604 3,864 / 1,722 Heller (7) 2,940 / 1,302 1,932 / 861 Appy (102) 14,280 / 6,324 9,384 / 4,182 Meckel’s (2) 280/ 124 184 / 82 Pyloric (77) 21,560 / 9,548 14,168 / 6,314 Chole (31) 8,680 / 3,844 5,704 / 2,542 Pullthrough (20) 2,800 / 1,240 1,840 / 820 Spleens (21) 5,880 / 2,604 3,864 / 1,722 Adrenal (6) 1,680 / 744 1,104 / 492 UDT (15) 4,200 / 1,860 2,760 / 1,230 Varicocele (5) 1,400 / 620 920 / 410 Ovarian (2) 560 / 248 368 / 164 Total = 511 $187,180/$82,894 $123,004/$54,817

PAPS 2003PAPS 2003JPS 38:1837-1840, 2003JPS 38:1837-1840, 2003

Key Steps in Operation

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

Key Steps in Operation

2. Create 90 b/w cystic duct and CBD

What Do I Do If I Cut What Do I Do If I Cut

the Common Bile Duct?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 Experience2000 - 2006

• 224 Pts (65% female)(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 Experience2000-2006

• 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 0IPEG, 2007IPEG, 2007

Laparoscopy for Splenic Laparoscopy for Splenic ConditionsConditions

George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital

Kansas City, MO

Splenic Conditions

• ITP

• Spherocytosis

• Splenic cysts

• Wandering spleen

J Pediatr Surg 28:689-692, 1993J 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

• epithelial lining

• Pseudocysts (secondary)

• 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 2006APSA 2006

Wandering Spleen

Wandering Spleen

Laparoscopic Splenopexy

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

I.U. Experience1995 - 2006

231 patients

• Mean age 7.7 yrs

• Lap splenectomy – 223• 211 - total• 12 - partial

• Lap splenic cystectomy – 6

• Lap splenopexy - 2Ann Surg, in PressAnn Surg, in Press

I.U. Experience1995 – 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 PressAnn Surg, in Press

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