Gallbladder Disease in Infants and Children George W. Holcomb III, MD, MBA Children’s Mercy...
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Transcript of Gallbladder Disease in Infants and Children George W. Holcomb III, MD, MBA Children’s Mercy...
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
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
Why?
• Surgeon knows at time of laparoscopic cholecystectomy whether CBD (laparoscopic or open) exploration needed
• Potentially avoids a third anesthesia and operation
Cholangiography
• 1990-1995: Reasonable to perform cholangiography to become facile with technique
• 2006: Most surgeons have become facile with this technique
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 $2008.91
Stab Incision Technique
• 2 cannulas
• 2 stab incisions
J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4
Nissen (14) 2 3
Heller Myotomy (7) 2 3
Appendectomy (102) 2 1
Meckel’s Diverticulum (2) 2 1
Pyloromyotomy (77) 1 2
Cholecystectomy (31) 2 2
Pullthrough (20) 2 1
Splenectomy (21) 2 2
Adrenalectomy (6) 2 2
UDT (15) 1 2
Varicocele (5) 1 2
Ovarian (2) 1 2
Totals (511) 714 1337
PAPS 2003PAPS 2003JPS 38:1837-1840, 2003JPS 38:1837-1840, 2003
Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) 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
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)
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
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
• 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
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