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Gallbladder Disease in Infants and Children

Gallbladder Disease in Infants and Children. George W. Holcomb III, MD, MBA Children’s Mercy Hospital Kansas City, Missouri. Biliary Disease. Gallstones Hemolytic disease Non-hemolytic disease Biliary dyskinesia Acalculous disease. Nonhemolytic Total parenteral nutrition

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Gallbladder Disease in Infants and Children

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

  2. Biliary Disease • Gallstones • Hemolytic disease • Non-hemolytic disease • Biliary dyskinesia • Acalculous disease

  3. 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 Risk Factors for Cholelithiasis in Infants and Children

  4. 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

  5. Pilot Study

  6. Pilot Study

  7. Complicated Cholelithiasis • Acute cholecystitis • Jaundice • Pancreatitis

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

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

  10. SUSPECTED CHOLEDOCHOLITHIASIS(Pre-operatively) Management Options

  11. Management Options • Pre-op ERCP, sphincterotomy, stone extraction • Laparoscopic or open CBD exploration at time of cholecystectomy • Post-op ERCP, sphincterotomy, stone extraction

  12. Factors • Surgeon’s experience with laparoscopic CBD exploration • Availability of an endoscopist to perform ERCP inchildren

  13. Algorithm Suspected Choledocholithiasis

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

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

  16. IS ROUTINE CHOLANGIOGRAPHY NEEDED?

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

  18. Cholangiography • To evaluate for CBD stones • To define anatomy

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

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

  21. Financial analysis of preoperative ultrasonography versus intraoperative cholangiography for detection of choledocholithiasis at Children's’ Mercy Hospital, Kansas City MO

  22. Cholangiography Cystic Duct Cannulation Kumar Clamp Technique

  23. Kumar Clamp Technique Surg Endosc 8:927-930, 1994

  24. Where do I place the instruments/ports?

  25. Port Placement

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

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

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

  29. Key Steps in Operation • Begin dissection high on gallbladder to expose triangle of Calot

  30. Key Steps in Operation • Create 90 b/w cystic duct and CBD

  31. What Do I Do If I Cut the Common Bile Duct?

  32. 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

  33. CMH Experience 2000 - 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

  34. 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 0 IPEG, 2007

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

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

  37. 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)

  38. Patient Positioning

  39. Patient Positioning

  40. Personnel Positions

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

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

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

  44. Laparoscopic Splenectomy

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

  46. 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

  47. Splenic Cysts • Primary • epithelial lining • Pseudocysts (secondary) • no epithelial lining • often develop after trauma

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