Transcript THE ”ACUTE” SCROTUM - Children's Mercy Hospitals and Clinics

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
Ann Surg 191:626-635, 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 contraceptives
Hemolytic
Sickle cell disease
Spherocytosis
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 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 – 0 – 14 days
• 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
MANAGEMENT OF
SUSPECTED
CHOLEDOCHOLITHIASIS
(PRE-OPERATIVELY)
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 32:1116-1119, 1997
Algorithm
Suspected Choledocholithiasis
Why ERCP First?
• 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
CHOLANGIOGRAPHY
NEEDED?
Cholangiography
• 1990-1995: Reasonable to perform
cholangiography to become facile
with technique
• 2010: 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
2007
Immediate Pre-op
Evaluation with US
Ultrasound study
(including radiologist
fee)
Charges ($)
Intraoperative
Cholangiography
Charges ($)
307.67 15-minutes OR time
1500.00
C-Arm with
radiologist fee
TOTAL
365.41
Sterile drape for CArm
20.00
Cholangiocatheter
83.50
Contrast for
cholangiogram
40.00
$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
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
Key Steps in Operation
2. Create 90 b/w cystic duct and CBD
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
2000 - 2006
• 224 Pts (# female)
(12.9 yrs, 58.3 kg)
• Indication
•
•
•
•
•
•
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
• Mean operative time
•
77 min
Cholangiograms –
Intraoperatively
 Stones
 Cleared intraop
 Cleared postop
38
Preoperatively (ERCP)
 Stones found
17
• Ductal injuries
9
5
4
8
0
IPEG, 2007
J Laparoendosc Adv Surg Tech 18:127-130, 2008
www.cmhcenterforminimallyinvasivesurgery.com
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.