Transcript THE ”ACUTE” SCROTUM
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 191:626-635, 1980
Biliary Disease
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Gallstones
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Hemolytic disease
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Non-hemolytic disease
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Biliary dyskinesia
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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 contraceptives Hemolytic Sickle cell disease Spherocytosis Thalassemia
Biliary Dyskinesia
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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
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Epigastric/RUQ pain
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Nausea/vomiting
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Fatty food intolerance
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Painless jaundice
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Pancreatitis
Imaging Studies
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Ultrasound
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Radionucleide gallbladder emptying study (with CCK)
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Hepatobiliary scan
Complicated Cholelithiasis
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Acute cholecystitis
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Jaundice
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Pancreatitis
Timing of Cholecystectomy
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Non-complicated disease – 0 – 14 days
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Complicated disease
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Jaundice – following work-up
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Cholecystitis – 2-4 days
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Pancreatitis – once resolved
When to Suspect Choledocholithiasis?
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Elevated bilirubin (jaundice)
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Elevated lipase, amylase (pancreatitis)
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Dilated CBD or stone(s) in CBD on ultrasound
MANAGEMENT OF SUSPECTED CHOLEDOCHOLITHIASIS
Management Options
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Pre-op ERCP, sphincterotomy, stone extraction
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Laparoscopic or open CBD exploration at time of cholecystectomy
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Post-op ERCP, sphincterotomy, stone extraction (adults)
Factors
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Surgeon’s experience with laparoscopic CBD exploration
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Availability of an endoscopist to perform ERCP in children
14/131 suspected choledocholithiasis
J Pediatr Surg 32:1116-1119, 1997
Algorithm Suspected Choledocholithiasis
Why ERCP First?
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Surgeon knows at time of laparoscopic cholecystectomy whether CBD (laparoscopic or open) exploration is needed
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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
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1990-1995: Reasonable to perform cholangiography to become facile with technique
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2011: Most surgeons have become facile with this technique
Cholangiography
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To evaluate for CBD stones
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To define anatomy
My Approach
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Reserve cholangiography for cases where anatomy is unclear
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Use ultrasound pre-operatively to define CBD involvement
Pre-operative Ultrasound
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Prior to laparoscopic cholecystectomy
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Confirm stones, evaluate for CBD dilation or stones
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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 Ultrasound study (including radiologist fee) Charges ($) Intraoperative Cholangiography 307.67 15-minutes OR time Charges ($) 1500.00
C-Arm with radiologist fee Sterile drape for C Arm Cholangiocatheter 365.41
20.00
83.50
TOTAL Contrast for cholangiogram $307.67 TOTAL 40.00
$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 for a laparoscopic cholecystectomy?
Port Placement
Stab Incision Technique
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2 cannulas
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2 stab incisions
Key Steps in Operation 1.
2.
Begin dissection high on gallbladder to expose triangle of Calot 90 0 orientation cystic and common ducts
Critical View of Safety
What Do I Do If I Cut the Common Bile Duct?
Options
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Ligate duct
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wait for it to enlarge
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transfer to experienced biliary surgeon
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Repair laparoscopically
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Repair open
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interrupted sutures
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T – tube
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choledochojejunostomy at second operation
CMH Experience 2000 - 2006
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224 Pts (12.9 yrs, 58.3 kg)
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Indication
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Symptomatic gallstones Biliary dyskinesia Gallstone pancreatitis Gallstones/splenectomy Calculous cholecystitis Other 166 35 7 6 5 4 IPEG, 2007 J Laparoendosc Adv Surg Tech 18:127-130, 2008
CMH Experience 2000-2006
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Mean operative time 77 min
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Cholangiograms – Intraoperatively
Stones Cleared intraop Cleared postop Preoperatively (ERCP)
Stones found
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Ductal injuries 38 9 5 4 17 8 0 IPEG, 2007 J Laparoendosc Adv Surg Tech 18:127-130, 2008
SSULS Cholecystectomy
SSULS Cholecystectomy More Difficult Operation
SSULS Cholecystectomy
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SSULS Cholecystectomy Adults
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Can be performed safely but is more challenging Longer operating times (75 – 120 min) Difficulty with triangulation of instruments Additional ports/instruments - 10-30% 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
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CH-A: 25 cases Mean op time – 73 min (30-122) Additional instrument/port 22 pts (88%)
Nougues CP et al. JLAST 20:493-496, 2009
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CH-LA: 24 cases Mean op time – 97 min (65-145) Addt’l port – 2 pts (8%)
Emami CN et al. Am Surg 76:1047-1049,2010
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 46:904-907, 2011
SSULS Cholecystectomy Pediatrics
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Safe
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Effective
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Is it better than the 4-port technique?
CMH Prospective Randomized Trial
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Power analysis - 60 patients (59 to date)
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Primary outcome variable - operative time
Secondary Outcome Variables
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Complications
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Postoperative pain
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Cosmesis
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Infection rate
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Operative charges
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