Laparoscopic versus open cholecystectomy in children

What surgical approach would provide better outcomes in children and adolescents undergoing cholecystectomy? Results of a systematic review and meta-analysis

Background

There is a lack of evidence on the surgical approach for children and adolescents undergoing cholecystectomy. Therefore, the aim of this systematic review is to compare the safety and efficacy of minimally invasive cholecystectomy to open cholecystectomy in children and/or adolescents.

Main body

A search was conducted on MEDLINE, PubMed, Cochrane and Embase from inception to October 2018. We included comparative studies investigating outcomes following robotic-assisted, laparoscopic and/or open cholecystectomy in children and/or adolescents. The outcomes of interest included post-operative complication rate, operation time, length of hospital stay, post-operative pain and conversion to open procedure. The Newcastle-Ottawa Scale was used to assess the risk of bias. Meta-analysis was performed using random-effect models.

Twenty-one studies were included involving 927 children and/or adolescents. All, but one, compared outcomes between laparoscopic versus open cholecystectomy. The great majority of the included studies presented a low risk of bias. Patients undergoing laparoscopic cholecystectomy had less post-operative complications (RR: 0.57; 95%CI 0.35 to 0.94), reduced length of hospital stay (MD − 3.73; 95%CI − 4.88 to − 2.59), but longer operative time (MD 26.61; 95%CI 9.35 to 43.86) when compared to open cholecystectomy. The average conversion from laparoscopic to open cholecystectomy was 7% across studies.

Conclusions

The current evidence suggested that laparoscopic cholecystectomy in children and/or adolescents is safe resulting in lower rates of postoperative complications and length of stay, but longer operative times, when compared to the open approach.

PROSPERO registration

CRD42017067641

Level of evidence

Level III

Laparoscopic Versus Open Cholecystectomy in Pediatric Patients: A Propensity Score-Matched Analysis

Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is the gold standard for many conditions affecting the gallbladder; however, open cholecystectomy (OC) is offered as the initial approach in a surprisingly high percentage of cases. Materials and Methods: The Kids' Inpatient Database (1997-2012) was searched for International Classification of Disease, 9th revision, Clinical Modification procedure code (51.2x). LC and OC performed in patients <20 years old were identified. Propensity score-matched analyses using 39 variables were performed to isolate the effects of race, income group, location, gender, payer status, and hospital size on the percentage of LCs and OCs offered. Cases were weighted to provide national estimates. Results: A total of 78,578 cases were identified, comprising LC (88.1%) and OC (11.9%). Girls were 1.6 (CI: 1.4, 1.7) times more likely to undergo LC versus boys. Large facilities were 1.4 (1.3, 1.7) times more likely to perform LCs than small facilities. Children in lower income quartiles were 1.2 (1.1, 1.3) times more likely to undergo LC compared with those in higher income quartiles. Rates of LC were not affected by race, hospital location, or payer status. Conclusions: Risk-adjusted analysis of a large population-based data set demonstrated evidence that confirms, but also refutes, traditional disparities to minimally invasive surgery access. Despite laparoscopic gold standard, OC remains the initial approach in a surprisingly high percentage of pediatric cases independent of demographics or socioeconomic status. Additional research is required to identify factors affecting the distribution of LC and OC within the pediatric population.

Laparoscopic cholecystectomy for cholelithiasis in children with sickle cell disease

Patients with sickle cell disease (SCD) suffer from an increased incidence of gallstone formation due to hemolysis of sickled red blood cells; this leads to an increased level of bilirubin in secreted bile that becomes a nidus for pigment stone formation. Laparoscopic cholecystectomy (LC) is considered a standard operative procedure for gallstone disease mainly due to lower postoperative wound complaints, faster recovery, better postoperative cosmetic results, shorter hospital stay, and earlier return to work. Although numerous studies have been published addressing both the advantages and complications of LC in acute calcular cholecystitis, there is still limited evidence concerning the safety and efficacy of LC for the management of cholelithiasis in pediatric patients with SCD, and controversies remain unresolved. In this review, we aim to comprehensively study the available literature and propose evidence-based practice recommendations for the optimal management of gallstones in pediatric SCD patients. The current practice differs greatly depending on the prevalence of SCD in a particular geographic area. We acknowledge the limited number of patients reported, the lack of randomized control trials addressing the practice of specific recommendations, and the need for further evidence-based studies.

Laparoscopy in pediatric surgery: Implementation in Canada and supporting evidence

BACKGROUND/PURPOSE

The purpose of this study was to assess the diffusion of laparoscopy usage in Canadian pediatric centers and the relationship between uptake of laparoscopic surgery and the level of evidence supporting its use.

METHODS

National data on four pediatric laparoscopic operations (appendectomy, pyloromyotomy, cholecystectomy, splenectomy) were analyzed using the Canadian Institute for Health Information Discharge Database (2002-2013). The highest level of evidence to support the use of each procedure was identified from Cochrane, Embase, and Pubmed databases. Chi-square test for trend was used to determine significance and time to plateau.

RESULTS

There were 28,843 operations (open: 12,048; laparoscopic: 16,795). Use of laparoscopic procedures increased over time (p<0.0001). A plateau was reached for cholecystectomy (2006), splenectomy (2007), and appendectomy (2012), but not for pyloromyotomy. Laparoscopic pyloromyotomy in 2013 remains less diffused than the other procedures (p<0.0001). Laparoscopic appendectomy and pyloromyotomy are supported by level-1a evidence in children, whereas cholecystectomy and splenectomy are supported by level-1a evidence in adults but level-3 in children.

CONCLUSIONS

In Canada, it has taken a long time to reach high-level implementation of laparoscopic surgery in children. Laparoscopic cholecystectomy first reached plateau, whereas laparoscopic pyloromyotomy continues to increase but remains low despite high level of evidence in support of its usage compared to open surgery.

Gallstone disease in children

Gallstone disease in children is evolving, and for the previous 3 decades, the frequency for surgery has increased greatly. This is in part because of improved diagnostic modalities, but also changing pathology, an increased awareness of emerging comorbidities, such as childhood obesity, and other associated risk factors. This article outlines the pathophysiology, genetics, and predisposing factors for developing gallstones and includes a review of the literature on the current and more novel medical and surgical techniques to treat this interesting disease.

Single-incision laparoscopic cholecystectomy in children: a feasible alternative to the standard laparoscopic approach

PURPOSE

Our aim was to evaluate the outcomes of the single-incision laparoscopic (SIL) cholecystectomy compared with the standard 4-incision laparoscopic (SL) cholecystectomy.

METHODS

A retrospective chart review of consecutive patients undergoing cholecystectomy using the SIL approach from January 2008 to September 2010 was performed. These patients were compared with a cohort who underwent an SL cholecystectomy from January 2007 to June 2009. Demographics, operative times, length of stay, blood loss, and intravenous narcotic use was obtained from the charts. A nonpaired Student's t test was used to determine statistical significance.

RESULTS

We identified 40 patients in the SIL group and 68 in the SL group. Main diagnosis was cholelithiasis followed by gallstone pancreatitis and cholecystitis. The mean operative time for SIL cholecystectomies was 79.2 minutes vs 63 minutes in the SL group (P < .006). The average length of stay was 1.9 days in the SIL group vs 2.3 days in the SL group (P < .24). The mean intravenous narcotic use was 1 dose in the SIL group vs 2.9 doses in the SL group (P < .007). There were no intraoperative complications. At 1-month postoperative follow-up, all patients had satisfactory recovery.

CONCLUSION

Single-incision laparoscopic cholecystectomy is a safe and feasible alternative to the standard laparoscopic approach in children, even in the setting of acute disease.

Safety and long-term outcomes of endoscopic papillary balloon dilation in children with bile duct stones

BACKGROUND

Although experience with diagnostic and therapeutic ERCP in children is growing, little is known about the safety and technical outcomes of endoscopic papillary balloon dilation (EPBD) in pediatric patients with bile duct stones (BDSs).

OBJECTIVE

To assess the safety and long-term outcomes of EPBD in pediatric patients with BDSs.

DESIGN

Case study.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

This study involved 5 children who had BDSs combined with gallstones who underwent EPBD.

MAIN OUTCOME MEASUREMENTS

Successful EPBD, successful stone removal, procedure-related complications, and long-term outcomes.

RESULTS

ERCP was successful in all cases, with cannulation and subsequent EPBD. Stone removal was performed in 1 session in all patients. No EPBD-related complications were observed in any patient. After EPBD, 1 patient subsequently underwent laparoscopic cholecystectomy for gallstones. The remaining 4 were followed without surgery. In 2 patients, gallstones were spontaneously passed from the bile duct into the duodenum. During the follow-up period, over a mean of 7.1 years (range 3.7-9.3 years), no recurrence of BDSs was observed in any patient.

LIMITATIONS

Small number of patients.

CONCLUSIONS

Although BDSs are rare in pediatric patients, EPBD may be a safe and effective technique for the management of such stones in some children.

Lessons learned from the first 109 laparoscopic cholecystectomies performed in a single pediatric surgery center

BACKGROUND

Laparoscopic cholecystectomy (LC) is a frequent operation in adults but is seldom performed in children. A retrospective review of 109 consecutive patients who underwent LC over an 11-year period was performed to see what lessons were learned from this experience.

METHODS

From January 1996 to January 2007, a total of 109 patients were referred to our unit to undergo LC. Nine adult patients were excluded from the analysis. The remaining 100 pediatric patients form the basis of this report. Isolated cholecystectomies were performed using a four-trocar technique, with a fifth trocar added for cases in which splenectomy was required. One patient with main bile duct dilatation at preoperative echography underwent peroperative cholangiography.

RESULTS

We recorded three anatomic anomalies (3%), two involving the bile duct and one the cystic artery. We recorded four minor problems during surgery: In one case there was failure of the tip of reusable scissors, and in three cases there was a small perforation of the gallbladder during the dissection step. We recorded four (4%) postoperative complications, which required redo surgery: one patient with bleeding from the cystic artery; one case of dislocation of clips positioned on the cystic duct; and two patients with lesions of the main bile duct that had not been detected during surgery. The treatment consisted in choledojejunostomy on postoperative day 7 in one case and suture of the choledocus on a stent positioned using endoscopic retrograde cholangiopancreatography on postoperative day 5 in the second case. Both biliary complications occurred in patients more than 14 years of age. We also recorded one umbilical granuloma.

CONCLUSIONS

LC is an effective procedure in children. On the basis of our experience, it seems that major complications can occur even with experienced surgeons, and they are more frequent in teenagers. Biliary or vascular anomalies of the gallbladder are encountered in about 3% of patients.

Minilaparotomy cholecystectomy in children

AIM

Scarcity of paediatric cholelithiasis limits the obtainable experience in paediatric laparoscopic cholecystectomy (LPC). We report minilaparotomy cholecystectomy (MLC) in children which may be a useful alternative to LPC avoiding the added cost of disposable laparoscopic equipment.

METHODS

Nineteen cases underwent a retrograde MLC using a 2-4 cm transverse right upper quadrant incision. Various parameters were assessed.

RESULTS

Mean age at presentation was 10.87 years, mean length of the incision 2.8 cm, mean operative time 36.5 min, mean analgesic requirement 2 days, mean time to feed/ mobilize 1 day each, and mean duration of hospital stay was 2.7 days. All had satisfactory cosmetic result without postoperative complications.

CONCLUSIONS

MLC in children involves a small incision, excellent cosmetic scar and rapid postoperative recovery at relatively low cost. It is a good alternative to LPC.

Informed consent and choice in cholecystectomy

As patients and parents seek more information and the threat of litigation increases, the process of informed consent has assumed greater importance. Data from large adult experiences indicate that the risk of bile duct injury, although small, is greater with laparoscopic cholecystectomy (LC) than open cholecystectomy. This complication has not yet been documented in pediatric practice, where cholecystectomy is relatively uncommon. What method do parents and patients choose if consent is truly informed? Of 57 consecutive children undergoing cholecystectomy, an open procedure was specifically indicated in 20 (previous major gastrointestinal surgery in 11, concomitant major abdominal operation in four, and complex biliary tract disease in five) and LC in two (cystic fibrosis, severe autism). The remaining 35 patients were counseled in a standard manner about the relative merits of LC versus mini-cholecystectomy (MC) and allowed to choose. Specifically, they were informed that LC offers better cosmesis, less postoperative discomfort, and a shorter hospital stay, but in adults is associated with a slightly increased rate of bile duct injury (0.3-0.5% vs. 0.2%). All MCs were performed through a 4-cm incision. Parents chose LC in 23 cases and MC in 12. The median age of both groups was similar. No surgical complications occurred, and there were no conversions in the LC group. No patient had retained stones. LC patients were discharged home after a mean of 1.7 days and MC patients after 2.3 days (0.1 > p > 0.05). If an open or laparoscopic technique is not specifically indicated and if parents/patients are fully informed, a significant minority may opt for mini-cholecystectomy.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Results and complications of laparoscopic cholecystectomy in childhood

BACKGROUND

The purpose of our study was to evaluate the results and complications of laparoscopic cholecystectomy in a case series of 110 infants.

METHODS

Over a 5-year period (1993-98), we performed laparoscopic cholecystectomy in 110 pediatric patients. Surgery was performed at different institutions by three different surgeons. The patient population was composed of 69 girls and 41 boys; their ages ranged from 1 to 16 years (median, 8.5). All of the 110 children had symptomatic cholelithiasis, which was confirmed at ultrasound examination. An associated pathology was present in 27 patients (sickle cell disease in 17 cases, hereditary spherocytosis in seven cases, thalassemia in three); the other 83 infants were affected by idiopathic cholelithiasis. In 107 patients, the operation was performed using four ports; in three patients, it was done using five ports. In three patients, we also performed a concomitant splenectomy.

RESULTS

Median duration of simple cholecystectomy was 45 min (range, 25-75) and hospital stay ranged from 1 to 10 days (median, 2). Only 15 children required drainage. We had 17 complications in our series (15.5%), including a gallbladder perforation during dissection in 11 patients, a fall of stones into the abdominal cavity during extraction in one patient, and a trocar orifice infection in the postoperative period in five patients. At a maximum follow-up of five years (range, 1-5), all patients were doing well.

CONCLUSION

Laparoscopic cholecystectomy in children seems to be as effective as open surgery in cases of symptomatic cholelithiasis. In pediatric patients more than in adults, an accurate and precise dissection and a sound knowledge of possible congenital biliary abnormalities are essential to avoid any kind of complication.