1. Intraoperative Cholangiogram in Children Joshua Mourot July 21, 2011

2. Cholelithiasis in Children Occurs in 0.15 to 0.22% of children (10% in adults) Drastically reduced cholesterol-based disease: >70% of stones are pigmented (hemolytic disease  black, biliary tract infection  brown) Most common etiologies are chronic hemolytic disease (SCD, spherocytosis), prolonged PN and obesity Cholesterol stones most prevalent in obese adolescent females

3. Indications for Cholecystectomy Increased incidence of treatable conditions –Improved diagnostic tools –Premature infant survival –Organ transplant –Cystic fibrosis –Use of TPN –Recognition of biliary dyskinesia (GBEF <35%) as a treatable condition with LC Vegunta 2005 (Illinois)

4. Use of LC in Children Substantial increase (Miltenberg 2000) –20 year review from TC in 1984  36 cases –16 year review from TC in 1996  128 cases At Seattle Children’s (Waldhausen 1999) –185 cases from 1984 – 1996 –Increased incidence during study time period 4.4 LC/year (1984-90) 16.3 LC/year (1991-96) –More liberal US use, change in physician perception (more complications from gallstone disease)

5. Intraoperative Cholangiogram

6. Petelin 2002 –Sensitivity, 80-90% –Specificity, 76-97% –Low complication rates

7. When to perform IOC Waldhausen 2001 –Retrospective review of 100 consecutive LC –18 patients with CBD stones, 3 found with IOC only –High rate of negative pre-operative ERCP (4/9) for suspected CBD stones –63 underwent IOC  7 with post-op ERCP –Argument for routine IOC IOC would have avoided unnecessary use of ERCP in 4 patients (additional anesthetic) Risk of single complication from missed CBD stone is unacceptable (pre-op eval not 100%)

9. Selective use of IOC Mah 2004 (Toronto) –202 consecutive LC, 48 with suspected CBD stones (clinical, biochemical, radiological) –High negative pre-op ERCP rate (10/13, 77%) –0/154 unsuspected returned with symptoms –IOC and ERCP correlated in 6/6 cases where both were performed –Recommendation: No pre-op ERCP LC with IOC in suspected CBD only, post-op ERCP if stones present

11. Post-operative ERCP? Vrochides 2005 (Providence, RI) –Following positive IOC, patients were followed with US and labs –Ultimately 1/12 required ERCP on POD#2 (no major complications) –Recommend against routine ERCP for +IOC –33% complication rate for ERCP in children (pancreatitis, bleeding) –Spontaneous passage of CBD stones is higher in children 12

12. Additional options Kejriwal 2004 (Auckland) –MRCP equivalency to ERCP for CBD eval

13. Additional options Machi 2007 (Hawaii) –200 consecutive LC with LUS; IOC only used when biliary anatomy not clearly visualized –Sens 95%, Spec 100% –Recommend laparoscopic US and selective IOC (only when LUS not clear) –Claim more cost-effective to perform routine LUS with select IOC

14. Summary Pre-operative ERCP should not be done routinely for suspected choledocolithiasis Data exists to support selective or routine IOC Post-operative ERCP with positive intraop findings may be avoided in children given high rate of spontaneous clearance of CBD stones, given close post-op monitoring LUS with IOC may offer a cost-reducing, equally effective alternative to routine or selective IOC

15. References Kejriwal, et al. Magnetic Resonance Imaging of the common bile duct to exclude choledocholithiasis. ANZ J. Surg. 2004; 74: 619–621 Machi, et al. Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy. Surg Endosc (2007) 21: 270–274 Mah, et al. Management of Suspected Common Bile Duct Stones in Children: Role of Selective Intraoperative Cholangiogram and Endoscopic Retrograde Cholangiopancreatography. Journal of Pediatric Surgery, Vol 39, No 6 (June), 2004: pp 808-812 Miltenburg, et al. Changing Indications for Pediatric Cholecystectomy. Pediatrics 2000;105;1250 Nelson Textbook of Pediatrics Petelin, JB. Surgical management of common bile duct stones. Gastro Endo. 56; NO. 6 (SUPPL), 2002 Vegunta, et al. Biliary dyskinesia: The most common indication for cholecystectomy in children. Surgery 2005;138:726-33 Vrochides, et al. Is There a Role for Routine Preoperative Endoscopic Retrograde Cholangiopancreatography for Suspected Choledocholithiasis in Children? Arch Surg. 2005;140:359-361 Waldhausen, et al. Cholecystectomy Is Becoming an Increasingly Common Operation in Children. Am J Surg. 1999;177:364–367 Waldhausen, et al. Routine Intraoperative Cholangiography During Laparoscopic Cholecystectomy Minimizes Unnecessary Endoscopic Retrograde Cholangiopancreatography in Children. Journal of Pediatric Surgery, Vol 36, No 6 (June), 2001: pp 881-884