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

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Presentation on theme: "Gallbladder Disease in Infants and Children George W. Holcomb III, MD, MBA Children’s Mercy Hospital Kansas City, Missouri."— Presentation transcript:

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



4 Biliary Disease Gallstones Hemolytic disease Non-hemolytic disease Biliary dyskinesia Acalculous disease

5 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 SpherocytosisThalassemia

6 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

7 Pilot Study


9 Complicated Cholelithiasis Acute cholecystitis Jaundice Pancreatitis

10 Timing of Cholecystectomy Non-complicated – 2 weeks Complicated Jaundice – following work-up Cholecystitis – 2-4 days Pancreatitis – once resolved

11 When to Suspect Choledocholithiasis? Elevated bilirubin (jaundice) Elevated lipase, amylase (pancreatitis) Dilated CBD or stone(s) in CBD on ultrasound

12 SUSPECTED CHOLEDOCHOLITHIASIS (Pre-operatively) Management Options

13 Pre-op ERCP, sphincterotomy, stone extraction Laparoscopic or open CBD exploration at time of cholecystectomy Post-op ERCP, sphincterotomy, stone extraction

14 Factors Surgeon’s experience with laparoscopic CBD exploration Availability of an endoscopist to perform ERCP in children


16 Algorithm Suspected Choledocholithiasis

17 Why? Surgeon knows at time of laparoscopic cholecystectomy whether CBD (laparoscopic or open) exploration needed Potentially avoids a third anesthesia and operation

18 Disadvantage A number of ERCPs will be performed in patients that do not have CBD stones


20 Cholangiography 1990-1995: Reasonable to perform cholangiography to become facile with technique 2006: Most surgeons have become facile with this technique

21 Cholangiography To evaluate for CBD stones To define anatomy

22 One Surgeon’s Approach Reserve cholangiography for cases where anatomy is unclear Use ultrasound pre-operatively to define CBD involvement

23 Pre-operative Ultrasound Prior to laparoscopic cholecystectomy Confirm gallbladder stones, evaluate for CBD dilation or stones Cost-effective strategy

24 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) 307.6715-minutes OR time1500.00 C-Arm with radiologist fee 365.41 Sterile drape for C- Arm 20.00 Cholangiocatheter83.50 Contrast for cholangiogram 40.00 TOTAL$307.67TOTAL$2008.91

25 Cholangiography Cystic Duct Cannulation Kumar Clamp Technique

26 Surg Endosc 8:927-930, 1994

27 Where do I place the instruments/ports?

28 Port Placement

29 Stab Incision Technique 2 cannulas 2 stab incisions J Pediatr Surg 38:1837-1840, 2003

30 The Use of Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003

31 Cost Savings from Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003

32 Key Steps in Operation 1.Begin dissection high on gallbladder to expose triangle of Calot

33 Key Steps in Operation 2.Create 90  b/w cystic duct and CBD

34 What Do I Do If I Cut the Common Bile Duct?

35 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

36 CMH Experience 2000 - 2006 224 Pts (65% female ) (12.9 yrs, 58.3 kg) Indication Symptomatic gallstones166 Biliary dyskinesia 35 Gallstone pancreatitis 7 Gallstones/splenectomy 6 Calculous cholecystitis 5 Other 4 IPEG, 2007

37 CMH Experience 2000-2006 Mean operative time77 min Cholangiogram – Preoperatively (ERCP)17 Stones8 Intraoperatively38 Stones9 Cleared intraop5 Cleared postop 4 Postoperatively (ERCP)2 Stones0 Ductal injuries0 IPEG, 2007

38 Laparoscopy for Splenic Conditions George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

39 Splenic Conditions ITP Spherocytosis Splenic cysts Wandering spleen J Pediatr Surg 28:689-692, 1993

40 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)

41 Patient Positioning


43 Personnel Positions

44 Laparoscopic Splenectomy ITP, spherocytosis Port placement (2) cannulas (5, 12) (2) stab (3 mm) incisions Instruments Harmonic scalpel (5 mm) Articulating stapler (12 mm)

45 Laparoscopic Splenectomy Operative Steps Divide spleno-colic ligament, then short gastrics Clip artery Autotransfuse pt Protects stapler malfxn

46 Laparoscopic Splenectomy Operative Steps Divide spleno-renal lig. Articulating stapler across hilum Bag specimen, morcellate extracorporally

47 Laparoscopic Splenectomy

48 Issues How large is too large? 28 cm. – Splenic artery ligation helpful Can divide spleen (spherocytosis) with harmonic, if necessary

49 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

50 Splenic Cysts Primary epithelial lining Pseudocysts (secondary) no epithelial lining often develop after trauma

51 Laparoscopic Splenic Cystectomy First step is decompression of cyst

52 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

53 European Experience 3 European centers (Mainz, Mannheim, Hannover) 1995 - 2005 14 pts (median 8.5 yr) 10 recurrences (71%) APSA 2006

54 Wandering Spleen


56 Laparoscopic Splenopexy J Pediatr Surg 42:E23-27, 2007

57 I.U. Experience 1995 - 2006 231 patients Mean age 7.7 yrs Lap splenectomy – 223 211 -total 12 -partial Lap splenic cystectomy – 6 Lap splenopexy- 2 Ann Surg, in Press

58 I.U. Experience 1995 – 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 Press


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