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Rauh J, Dantes G, Wallace M, Collings A, Sanin GD, Cambronero GE, Bosley ME, Ganapathy AS, Patterson JW, Ignacio R, Knod JL, Slater B, Callier K, Livingston MH, Alemayehu H, Dukleska K, Scholz S, Santore MT, Zamora IJ, Neff LP. Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study. J Pediatr Surg 2024; 59:389-392. [PMID: 37957103 DOI: 10.1016/j.jpedsurg.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. METHODS A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. RESULTS Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05). CONCLUSION Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jessica Rauh
- Wake Forest School of Medicine, Winston Salem, USA.
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- Wake Forest School of Medicine, Winston Salem, USA
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2
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Ignacio RC, Kelley-Quon LI, Ourshalimian S, Padilla BE, Jensen AR, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Wang K. Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children. J Am Coll Surg 2023; 236:961-970. [PMID: 36786471 DOI: 10.1097/xcs.0000000000000650] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children. STUDY DESIGN A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05. RESULTS A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL. CONCLUSIONS Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.
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Affiliation(s)
- Romeo C Ignacio
- From the Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA (Ignacio)
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ (Padilla)
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco School of Medicine, and Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, CA (Jensen)
| | - Stephen B Shew
- Department of Pediatric General Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA (Shew)
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR (Lofberg)
| | - Caitlin A Smith
- Department of Pediatric General Surgery, Seattle Children's Hospital, Seattle, WA (Smith)
| | - Jonathan P Roach
- Department of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO (Roach)
| | - Samir R Pandya
- Department of Pediatric General and Thoracic Surgery, University of Texas Southwestern, Dallas, TX (Pandya)
| | - Katie W Russell
- Division of General Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT (Russell)
| | - Kasper Wang
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
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Rauh JL, Ganapathy AS, Bosley ME, Rangecroft A, Zeller KA, Sieren LM, Petty JK, Pranikoff T, Neff LP. Making common duct exploration common-balloon sphincteroplasty as an adjunct to transcystic laparoscopic common bile duct exploration for pediatric patients. J Pediatr Surg 2023; 58:94-98. [PMID: 36283848 DOI: 10.1016/j.jpedsurg.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has well-established benefits for managing pediatric choledocholithiasis. However, providers increasingly favor ERCP pre-or-post laparoscopic cholecystectomy (ERCP+LC) due to perceived complexity of LCBDE. We refined a stepwise method employing wire-ready balloon dilation of the Sphincter of Oddi. This study compares outcomes of balloon sphincteroplasty (LCBDE+BSP) with standard transcystic LCBDE (LCBDE-STD) and ERCP+LC. METHODS We performed a retrospective chart review of pediatric patients who underwent LCBDE-STD and LCBDE+BSP since 2018. A report of consecutive choledocholithiasis patients prior to 2018 yielded an ERCP+LC cohort. Age, operative time, complications, and length of stay (LOS) were compared across all groups. Success rate and fluoroscopy time were compared between LCBDE groups. RESULTS 44 patients were identified (14:LCBDE-STD; 15:LCBDE+BSP; 15:ERCP+LC) . There was no difference in patient age or BMI. Operative time was longer in the LCBDE+BSP group (p =< 0.05). ERCP+LC demonstrated increased LOS (4.36 ± 2.78 vs 1.31 ± 0.93; p =< 0.05) and complications compared to LCBDE groups including three stent placements and one stent migration. LCBDE+BSP had a higher success rate than LCBDE-STD (100% vs 78%; p = 0.06). The three patients who failed LCBDE-STD required postoperative ERCP. Average fluoroscopy time was not significantly impacted by addition of sphincteroplasty. CONCLUSION Incorporating LCBDE into standard management of pediatric choledocholithiasis reduces LOS and avoids additional invasive procedures regardless of the specific technique employed. This stepwise approach to wire-ready cholangiography with balloon sphincteroplasty is a viable method for LCBDE that utilizes techniques familiar to pediatric surgeons and provides definitive management under a single anesthetic. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jessica L Rauh
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States.
| | - Aravindh S Ganapathy
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States
| | - Maggie E Bosley
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States
| | - Alexa Rangecroft
- Wake Forest Baptist Medical Center School of Medicine, Winston Salem, NC, United States
| | - Kristen A Zeller
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Leah M Sieren
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - John K Petty
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Thomas Pranikoff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
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Grosshauser M, Ohletz T, Oesch V, Muller CO. Tips and Tricks—3 Use Cases of Interdisciplinary Knowledge Transfer in Minimally Invasive Pediatric Surgery. CHILDREN 2022; 9:children9091270. [PMID: 36138579 PMCID: PMC9497707 DOI: 10.3390/children9091270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022]
Abstract
In the pediatric surgical environment, we can enrich our knowledge and improve our skills through interdisciplinary knowledge transfer in exchange with other surgical or even non-surgical disciplines. To demonstrate this, we present in this article three patient cases of method transfer enabling new techniques in minimally invasive pediatric surgery. 1. The somewhat modified application of the AeroStat rigid tip laparoscopic cholangiography catheter during the single-step laparoscopic cholecystectomy facilitates the safe intraoperative cholangiography with common bile duct flushing. 2. A magnetic rod is used during laparoscopic enterotomy to locate and retrieve ingested magnets. 3. Using a patient-specific MRI 3D model representing a syndromic high anorectal malformation improves surgical planning and parental education.
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Affiliation(s)
- Mareike Grosshauser
- Department of Paediatric Surgery, Cantonal Hospital Aarau, Tellstrasse 25, 5000 Aarau, Switzerland
- Correspondence: ; Tel.: +41-62-838-2767
| | - Tim Ohletz
- Department of Radiology and 3D Lab, Cantonal Hospital Aarau, Tellstrasse 25, 5000 Aarau, Switzerland
| | - Valérie Oesch
- Department of Paediatric Surgery, Cantonal Hospital Aarau, Tellstrasse 25, 5000 Aarau, Switzerland
| | - Cécile Olivia Muller
- Department of Paediatric Surgery, Cantonal Hospital Aarau, Tellstrasse 25, 5000 Aarau, Switzerland
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Laparo-Endoscopic Rendez-Vous in the Treatment of Cholecysto-Choledocolithiasis in the Pediatric Population. J Pediatr Gastroenterol Nutr 2022; 74:819-822. [PMID: 35258502 DOI: 10.1097/mpg.0000000000003444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The incidence of choledocolithiasis is reported to be increasing in children. As for the adult population, several different therapeutic strategies have been described, however it is unclear which of those should be considered the gold standard. There is evidence-based literature in adults that supports a combined "rendez-vous" endoscopic retrograde cholangiopancreatography-laparoscopic cholecystectomy technique. This allows management of the choledocholithiasis during the same anesthetic episode as the cholecystectomy. By contrast, there are just two case reports in children reporting this approach. The aim of this study is to report our experience with this technique in a series of children with choledocholithiasis. METHODS All patients who underwent the "rendez-vous technique" at our institution between 2009 and 2020 were reviewed and evaluated for outcomes and complications. RESULTS Eleven children with cholecysto-choledocholithiasis were evaluated: the procedure was successful in 10 whereas in one patient it was aborted due to technical difficulties. All patients resolved their clinical condition without major complications. CONCLUSION To our knowledge, this is the first consistent series of "rendez-vous technique" in the pediatric population, proving its feasibility and safety.
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Wong MCY, Incerti F, Avanzini S, Palo F, Sertorio F, Damasio MB, Arrigo S, Gandullia P, Mattioli G. Cholelithiasis management in a third-level pediatric center: case series and literature review. Updates Surg 2022; 74:963-968. [DOI: 10.1007/s13304-021-01227-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/22/2021] [Indexed: 01/26/2023]
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Intraoperative cholangiography: a stepping stone to streamlining the treatment of choledocholithiasis. Surg Endosc 2021; 36:4885-4892. [PMID: 34724581 DOI: 10.1007/s00464-021-08840-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND An estimated 8-15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP). METHODS The charts of 1715 patients in the institutional NSQIP database who underwent cholecystectomy between October 1st, 2005 and September 30th, 2019 were retrospectively reviewed. Patients who underwent cholecystectomy in relation to a malignancy diagnosis or who underwent an ERCP in a different index hospitalization were excluded. Main outcomes included hospital length of stay (LOS), post-operative morbidity, and rate of readmissions. RESULTS Of the 1409 patients included in the final analysis, 185 patients underwent ERCP, while 95 patients underwent IOC. Use of IOC compared to preoperative ERCP resulted in a shorter LOS (2.6 vs. 5.3 days, p < 0.001), lower rate of readmission (1.1% vs. 6.5%, p = 0.040), and similar rates of post-operative complications. Mean operative time increased by only 15 min in the IOC compared to the ERCP group (129 vs.114 min, p = 0.047). Additional variables that increased LOS on multivariable logistic regression included age, ASA classification, post-operative complications, and increased number of preoperative tests. CONCLUSIONS This study demonstrates that use of IOC during cholecystectomy results in shorter LOS and fewer readmissions compared to ERCP. Future studies comparing these two approaches should focus on patient randomization, a cost-effectiveness analysis, and identifying barriers to implementation of a one-stage approach in the management of suspected choledocholithiasis.
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Bosley ME, Zamora IJ, Neff LP. Choledocholithiasis-a new clinical pathway. Transl Gastroenterol Hepatol 2021; 6:35. [PMID: 34423156 DOI: 10.21037/tgh-20-172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/18/2020] [Indexed: 01/07/2023] Open
Abstract
The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.
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Affiliation(s)
- Maggie E Bosley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Irving J Zamora
- Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Complications in pediatric laparoscopic cholecystectomy: systematic review. Updates Surg 2020; 73:69-74. [PMID: 32939742 DOI: 10.1007/s13304-020-00888-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
Laparoscopic cholecystectomy (LC) is the gold standard for surgical management in symptomatic children, but it is not without complications, bile duct injury being among the most feared. This study reviewed the complications of LC in children. MEDLINE/PubMed, CENTRAL and Lilacs were reviewed for LC. Studies in patients ≤ 18 years of age published in English, Portuguese or Spanish were selected by two independent reviewers. Data were collected for patients' characteristics, surgical information, complications, mortality and follow-up. Twenty-four papers were identified and offered 2783 patients. Mean age was 11 years (3 months-18 years). In the 93/2783 (3.3%) complications, single-port procedures were associated with seven (7.5%), 3/4-port with 81 (87.1%) and the number of ports were not specified in five. Routine cholangiography was not part of the protocol in any of the reports. Complications included wound issues (n = 24), perforation (n = 14), bleeds (n = 13), biliary tree complications (n = 9), sickle cell crisis (n = 8), fever (n = 6), leaks (n = 4), pain (n = 3), nausea/emesis (n = 3) and others (n = 9). Two of these patients had a history of obesity and cholecystitis and only two biliary tree lesions were diagnosed intra-operatively. Seventeen cases (18.3%) required re-intervention: 15 surgical and two endoscopic. Issues related to biliary tree included: common bile duct lesion (n = 6), biliary fistula (n = 3), clip dislocation from cystic duct (n = 1), cholangitis (n = 1) and calculus (n = 1). There was no mortality, and the mean follow-up period was 10.3 months (1 month-5 years). LC is safe in children and, although most complications are minor, almost 1/5 complications require interventions, mostly due to bleeding and biliary tree complications. Mortality has not been reported in pediatric LC.
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