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Pediatric laparoscopic biliary tract surgery
Pediatric Laparoscopic Biliary Tract Surgery By Edward P. Tagge, Andre Hebra, Aron Goldberg, John C. Chandler, Stephen Delatte, and H. Biemann Othersen, Jr Charleston, South Carolina Laparoscopic cholecystectomy is being performed with increasing frequency in children. The authors discuss the presentation, surgical technique, overall results, and potential complications associated with pediatric laparoscopic biliary tract surgery, citing a large personal experience as well as that reported in the literature. Copyright © 1998 by W.B. Saunders Company
HE FIRST laparoscopic cholecystectomy was performed in 1987 in France by Dubois. Soon after its introduction, the procedure was widely adopted in both the United States and Europe for management of cholelithi.asis in adults. Pediatric surgeons were slower to embrace thi s new technique for a variety of reasons: (1) fewer patients with cholelithiasis, (2) space limitations in the pediatric abdomen, (3) the lack of pediatric-sized laparoscopic instruments, and (4) the need for accomplished surgeons to acquire new operating skills. Thus, initial series describing the outcome of laparoscopic cholecystectomy in children were quite small,I -3 with "larger" series having only 20 to 30 patients. 4 •5 However, a few institutions, including the Medical University of South Carolina, eventually acquired significant experience with laparoscopic cholecystectomy in children. We developed this experience·because of (1) an early commitment to laparoscopic techniques for children, (21 access to a large population of pediatric patients with sickle cel1 disease, and (3) the establishment of our Digestive Disease Center, with its wide referral base owing to its outstanding expertise in djagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). This report will attempt to highlight the rep0l1ed experience with pediatric laparoscopic cholecystectomy, intermingled with our personal experience.
T
PRESENTATION
Severa] investigators have commented that cholelithiasis is being recognized with increasing frequency in pediatric patients. 6 In Lugo-Vincente's 1997 study, 83 patients between 21 months and L8 years of age were identified. In his series, females (76%) with cJassic biliary symptoms predominated, with abnormal liver chemistry values, obesity, and elevated triglyceride levels From the Division of Pediatric Surgery, Medical Uni versity of South Carolina. Charlestoll. sc. Address reprint requests to Edward P. Tagge, MD, Pediatric Surgery, 900 MUSC Complex. Suite 633. Charleston, SC 29425. Copyright © 1998 by W.B. Saunders Company 1055-8586/98/0704-0008$08.00/0 202
comprising the most significant predisposing factors. Other investigators have noted that a significant minority of gallstones in children are idiopathic, whereas the majority are associated with the common predisposing factors for pediatlic cholelithiasis: chronic hemolysis, obesity, pregnancy and oral contraceptive use, total parenteral nutrition (TPN)-induced cholestasis, congenital heart disease and polycythemia, and ileal disease (eg, cystic fibrosis) or resection. In our series of 114 patients managed between December 1990 and October 1997, chronic hemolysis from sickle cell disease was the etiology for 83 patients (73 %) ; idiopathic stones was our next largest category. The diagnosis of cholelithiasis is made almost exclusively with ultrasonography, which is safe, relatively inexpensive, and usually painless. Until recently, the diagnosis of choledocholithiasis has been confirmed primarily by ERCP, although in a few cases ultrasonography has correctly identified common duct stones. Ultrasound evaluation more often provides clues that concomitant choledocholithiasis exists . However, because ERCP is an invasive procedure that usually requires general anesthesia (except in older pediatric patients), we are currently investigating the utility of magnetic resonance cholangiopancreatography (MRCP) to diagnose common duct stones. Most children with cholelithiasis have symptoms that have precipitated the diagnosis, and almost all investigators would agree that cholecystectomy is indicated in children with symptomatic cholelithiasis. As in adults, the management of either asymptomatic cholelithi asis or cholelithiasis with atypical symptoms (eg, the sickle cel1 patient with nonspecific abdominal pain) is more controversial. With accumulating data showing that chi1dren with comorbid factors (such as congenital heart disease or sickle cell anemia) have higher rates of morbidity and mortality associated with their cholelithiasis, such children are being referred more frequently by primary care physicians. That has been our experience in patients with sickle cell disease. Before December 1990, when we performed our first laparoscopic cholecystectomy, only one or two children with sickle cell anemia underwent open cholecystectomy each year, usually owing to complications of their disease. Since 1991, we have seen a marked increase in referral of sickle cell patients with cholelithiasis and a decrease in the acuity of their gallbladder disease. 4 Seminars in Pediatric Surgery, Vol 7, No 4 (November), 1998: pp 202-206
203
LAPAROSCOPIC BILIARY TRACT SURGERY
TECHNIQUE
Preoperative Management Preoperative management is an important aspect of all surgical procedures, especially for patients with sickJe cell disease. Initially, all sickle ce11 patients scheduled for operation underwent exchange transfusion to lower their hemoglobin S percentage to less than 30%. However, from 1990 to 1993, our patients with sickle ce11 disease were entered into a national preoperative transfusion study protocol, being randomized to either (A) exchange transfusion to raise the hemoglobin level to 10 mg% and decrease hemoglobin S to less than 30% or (B) simple transfusion to increase the hemoglobin level ~o to mg%, independent of the hemoglobin S percentage. The results of this study showed that a conservative transfusion regimen was as effective as an aggressive regimen in preventing perioperative complications in patients with sickle cell anemia, and also resulted in only half as many transfusion-associated complications. 7 All our subsequent patients with sickle cell disease have been managed using simple transfusion to increase the hemoglobin level to 10 mg%.
Operative Technique: Laparoscopic Cholecystectomy Initially the preparation for laparoscopic cholecystectomy included insertion of a Foley catheter and orogastric tube, in anticipation of the induction of pneumoperitoneum with use of a Veress needle. However, after our early experience, we began and have continued to use the Hasson open approach for placement of the umbilical trocar; subsequently we discontinued the practice of inserting a Foley catheter. Although initjany intraabdomina] pressure was maintained at about 15 mm Hg, our subsequent impression that high intraabdominal pressures caused increased postoperative abdominal pain has led us to reduce the pressure to as low as possible, usually less than 12 mm Hg. A 30° angled laparoscope is inserted through a 10-mm (or more recently, 5-mm) nondisposable umbiljcal trocar, and three additional 5-mm nondisposable trocars are placed under direct vision, their placement being individualized according to the patient's body habitus and previous surgical incisions. For infants and young children, for whom "instrument congestion" and very short working distances can be a problem, these . ports must be positioned as far from the right upper quadrant as possible. The left-upper-quadrant trocar is positioned between the xiphoid and umbilicus, to the left of the midline. Tills trocar, through which the main surgical dissection is performed, is positioned as high in the left upper quadrant as possible, to provide an improved angle and thus safer approach to the cystic duct and artery. Two additional trocars are placed on the right side of the abdomen, either in line with or below the
umbilicus, one in the midclavicular 1ine and one in the anterior axillary line. Most of our laparoscopic cholecystectomies have been initiated by intraoperative cholangiography, to determine the anatomy of the cystic duct as well as identify the presence of common duct stones. Cholangiography is performed via a 16-gauge through-the-needle Intracath (Becton-Dickinson , Sandy, UT), which is advanced through the abdominal wall and into the fundus of the gallbladder. Fluoroscopy is used to visualize filling of the gallbladder, cystic duct, common bile duct, and eventually the duodenum. Special care is taken to identify the course of the cystic duct and its junction with the common duct, to help decrease the possibility of common duct injury. The gallbladder is put on tension with ratcheted graspers placed through the right-sided trocar , driving the fttndus of the gallbladder over the liver while retracting the infundibulum laterally. Lateral retraction of the infundibulum is very important because superior retraction of the infundibulum has been identified as one of the technical maneuvers that predisposes to common bile duct injury. The cystic duct is isolated with great care, and its junction with the gallbladder is totally exposed using hook cautery. Three hemoclips are placed across the duct, which is then divided as close to the gallbladder as possible, leaving two clip on the cystic duct stump. In identical fashion, the cystic artery is identified and divided close to the gallbladder. The gal lbladder is dissected from the liver bed in retrograde fashion, and is removed through the umbilical incision under direct vision.
Operative Technique: Laparoscopic Common Duct Exploration Dependi.ng on the experience of the surgeon and the availability and skill of the therapeutic endoscopist, common duct stones can be handled via (1) open common bile duct exploration (CBDE), (2) postoperative ERCP, (3) intraoperative ERCP, or (4) laparoscopically. For surgeons who choose intraoperative or postoperative ERCP, placement of a small guide wire (0.035 in) through the cystic duct (secured by an endoloop) and into the duodenum may significantly decrease the likelihood of failure of the subsequent therapeutic ERCP. Laparoscopic common duct exploration can be performed in two ways: transcystically or via diTect choledochotomy. Transcystic CBDE is begun with a hemoclip pJaced across the junction of the cystic duct and gallbladder. A small incision is made in the cystic duct, which prov.ides access to the common duct. Using fluoroscopy, irrigation of the common duct and transcystic basket retrieval are attempted initially. If unsuccessful, cystic duct dilatation and choledochoscopy is attempted. Using
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a flexible choledochoscope, basket retrieval under direct visua1ization is tried, and, if unsuccessful, stone fragmentation using an electrohydrauJic lithotriptor can be performed. For the advanced laparoscopist, choledochotomy and direct stone removal can be performed if all else fails. This can be facilitated by placement of two retraction sutures on either side of the common duct, which are brought through the anterior abdominal wall for improved common duct exposure and stabilization (personal communication, G.W. Holcomb III). After laparoscopic choledochotomy, most investigators recommend placement of a T-tube if a sphincterotomy had not been performed previously. RESULTS
Laparoscopic Cholecystectomy From December 1990 through October 1997, laparoscopic cholecystectomy was attempted in 114 patients at our institution. The age range was 6 months to 23 years (mean, 12.3 years). Conversion to open cholecystectomy was required for only 3 patients (2.6%): one because of massive hepatomegaly, one owing to a very short cystic duct with multiple common duct stones, and the third because of the patient's small size (6 months old, early in our series). Intraoperative cholangiography showed unsuspected choledocholithiasis in seven patients (6%). Their management is detailed below. To date, no patient has suffered bile duct injury or required management of a biloma. The postoperative length of stay has averaged 2.5 days, despite the high percentage of patients with sickle cell disease and their comorbid conditions. Forty-eight percent of the patients were discharged by 24 hours postoperatively, and 80% were discharged within 48 hours.
Choledocholithiasis There are several algorithms for the management of choledocholithiasis in adults, based mainly on the timing of endoscopic retrograde cholangiopancreatography (ERCP) and the indications for open common duct exploration. Until recently, little had been written on the management of pediatric choledocholithiasis. Early reports addressing this issue in children, particularly those with sickle cel1 anemia known to be associated with a high incidence of choledocholithiasis, indicated that the sequential approach of ERCP with stone extraction followed by laparoscopic cholecystectomy was safe and effective. 8- IO For instance, Newman et aI, in a review of two pediatric surgical services, preoperatively identified 14 of 131 children (11 %) suspected of having common duct stones. 9 All had successful diagnostic ERCP, and eight children were noted to have common duct stones, all which were removed successfully using sphincterotomy or sphincter dilation. However, in six children
(43%) no stones were noted. Laparoscopic cholecystectomy was then performed a mean of 3.8 days after ERCP. In none of the eight children with common duct stones were retained stones noted. Of their remaining 117 children undergoing primary laparoscopic cholecystectomy, only one had an unsuspected common bile duct stone, which was treated successfully by laparoscopy. Because of our large experience with sickle cell disease in conjunction with a high-volume ERCP referral service at our Digestive Disease Center, we have had extensive experience with pediatric choledocholithiasis. Seven of our patients (6%) were noted to have unsuspected choledocholithiasis through routine intraoperative cholangiography. These patients were handled in a variety of ways. One child underwent open CBDE because of a very short cystic duct and many common duct stones. Two children underwent successful transcystic CBDE, using irrigation alone in one and stone fragmentation by EHL followed by irrigation in another. II In one child whose transcystic CBDE failed, postoperative ERCP with stone extraction was successful. Finally, because our therapeutic endoscopists are readily available, three children were able to have successful intraoperative ERCP with sphincterotomy and stone extraction. Seventeen additional patients suspected of having choledocholithiasis underwent ERCP, either preoperatively (n = 10) or after laparoscopic cholecystectomy (n = 7, with 5 of those patients referred to our Digestive Disease Center after having laparoscopic cholecystectomy at otherins6tutions).l2 AU patients had successful diagnostic ERCP, including a 6 month old. Ten children (59%) were noted to have common duct stones. All the stones were extracted endoscopically, including successful endoscopic removal of an impacted ampulJary stone after an open CBDE (at whkh time more than 100 stones had been removed). Based on these data, we recently altered our treatment aJgorithm for children with suspected choledocholithiasis. Before this review, we employed ERCP in a preoperative setting for any child suspected of having choledocholithiasis. However, three factors have led us to alter that algOl;thm: (1) the almost uniform success rate for both diagnostic and therapeutic ERCP, removing the onus to perform the procedure before laparoscopic cholecystectomy, (2) the unexpectedly high percentage (41 % in our series, 12 43% reported by Newman et al,9 62% noted by Gholson et al lO ) of normal ERCP findings in this preselected group of patients, which significantly increased cost and morbidity, without providing any clinical benefit, (3) our increasing ability to perform laparoscopic common duct explorations, either transcystically or via laparoscopic choledochotomy. Thus, we presently use the following algorithm for children with suspected choledocholithiasis. For the rare children who present with either
LAPAROSCOPIC BILIARY TRACT SURGERY
cholangitis or fulminant pancreatitis (suggestive of an impacted stone), we still employ preoperative ERCP with sphinterotomy (or sphincter dilation), stone removal, and internal stent placement. Those patients are discharged home, and return for their laparoscopic cholecystectomy and endoscopic stent removal several weeks later. The majority of our children, including those we suspect of having common duct stones, proceed directly to laparoscopic cholecystectomy with intraoperative cholangiography. If common duct stones are identified, transcystic CBDE is performed, with Japaroscopic choledochotomy reserved for select patients depending on the experience of the laparoscopist. If laparoscopic CBDE is unsuccessful, laparoscopic cholecystectomy is completed, and either intraoperative or postoperative ERCP is employed. Although we have had little experience with this new algorithm, we are hopeful that it will decrease both cost and morbidity by eliminating negative preoperative ERCP studies. Thus, ERCP would be reserved for common duct stones that are retained after laparoscopic cholecystectomy.
Complications There are little data in the literature regarding complications after pediatric laparoscopic cholecystectomy. In a report presented to the 42nd Annual International Congress of the British Association of Paediatric Surgeons in July 1995 (unpublished), we critically reviewed the complications that occun'ed in our first 50 patients, treated from December 1990 through October 1994. Most of these patients had sickle cell disease, and their complications were more often related to their comorbid disease than to the Japaroscopic cholecystectomy. We divided these patients into three groups, based on the timing of their complication (immediately, within 30 days of laparoscopic cholecystectomy, more than 30 days after laparoscopic cholecystectomy). Seven patients experienced complications during their initial hospital stay. Two patients had significant perioperative hemorrhage that required transfusion. One of them had significant bleeding from a cystic artery injury that eventual1y was controlled during the laparoscopic cholecystectomy. In the other child, significant abdominal pain and anemia developed during the first 24 hours postoperatively. Laboratory results showed not only a decreasing hematocrit but also a prothrombin time of 16.4 seconds (normal, ' < 11.4 seconds). Despite resuscitation with fresh frozen plasma, reexploration was required, whereupon a large hematoma in the liver bed was found, with no obvious bleeding source. The experience with this child, in conjunction with a report by Hatley et al,13 subsequently led us to perform routine preoperative screening of coagulation in all patients with sickle cell disease. Four patients experienced either pneumonia or significant
205
atelectasis with hypoxia, which required supplemental oxygen, chest physiotherapy, and a short course of antibiotics. Currently known as acute chest syndrome, this constellation of symptoms continues to be an important postoperative problem for patients with sickle cell disease. 14 One child had ventricular tachycardia immediately after surgery, which necessitated a 5-day stay in the intensive care unit and a 13-day overall postoperative stay. A child with acute lymphoblastic leukemia and Salmonella cholecystitis developed pseudomembranous colitis and was discharged 36 days after the laparoscopic cholecystectomy. Three patients, all with sickle cell disease, had complications within 30 days of the laparoscopic cholecystectomy, but after their initial discharge. All three returned complaining of abdominal pain different from their usual vasoocclusive pain. All three patients were readmitted to the ho&pital and underwent abdominal radiography, ultrasonography, and nuclear medicine imaging of their biliary tracts. No bile duct leaks, fluid collections, or pneumoperitoneum were identified. The patients were discharged within 4 days and had spontaneous resolution of their symptoms. Seven patients returned with complications after the 3~-day perioperative pedod. Five patients, all with sickle cell disease, returned with abdominal pain. However, this time the pain was similar to that experienced preoperatively, which had precipitated the laparoscopic cholecystectomy. All episodes responded to intravenous fluid hydration and parenteral analgesia. One child returned with obstructive jaundice and pancreatitis owing to a stone impacted at the ampuJ)a of Vater, which was removed successful1y by ERCP. The remaining chj]d, who had cystic fibrosis, returned with a symptomatic hernia in the left-upper-quadrant trocar site. These complications had a major impact on postoperative stay (10.9 days for those with compUcations v ] .6 days for those without complications), and thus overall cost, emphasizing the importance of these previou ly underappreciated problems. The surgeon and the patient's family must understand that laparoscopic cholecystectomy remains a major abdominal intervention with significant attendant risks, particularly for children who have additional comorbid factors. Fin aJI y, Schaffer et al from the Baylor CoJlege of Medicine pointed out th apparently undenecognized need for emergency cholecystectomy among the pediatric population. IS Of their 124 patients treated between 1980 and ] 996,25% of cholecystectomies were pelformed urgently, and those patients had a significantly higher risk of postoperative complications, including death. Their three deaths involved patients with congenital heart disease, thus making congenital heart disease an independent risk factor for gallstonerelated mortality. This study, and others noting an
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increased risk of complications in sickle cell patients who undergo emergency gallbladder management, 16- 18 suggest that earlier elective cholecystectomy might be appropriate for select children with comorbid diseases. Thus,
balancing the risklbenefit ratio of delayed versus early surgery for children with cholelithiasis and significant comorbid conditions will continue to be a challenge for both the primary care physician and pediatric surgeon.
REFERENCES L Dav idoff AM, Branum GO, Murray EA, et al: The technique of laparoscopic cholecystectomy in children. Ann Surg 2 15 : 186- 191, 1992 2. Moir CR, Donohue JH, van Heerden JA: Laparoscopic cholecystectomy in children: Initial ex peri ence and reco mmendations. J Pediatr Surg 27: 1066- 1068, 1992 3. Newman KD, Marmon LM, Attorri R, et al: Laparoscopic cholecystectomy in pedi atric pati ents. J Pediatr Surg 26: 1.184-1185, 199 1 4. Tagge E P, Otherse n HB, Jackson SM, et al: Impact of laparoscopic chol ecystectomy on the management of cholelithiasis in children with sickJe cell disease. J Pedi atr Surg 29:209-2 12, 1994 5. Holcomb GW, Sharp KW, Neblett WW, et al: Laparoscopic cholecystectomy in infants and children: Modification s and cost analysis. J Pedi alr Surg 29:900-904, 1994 6. Lugo-Vicente HL: Trends in management of gallbl adder di sorders in children. Pediao' Surg Jnt 12:348-352, 1997 7. Vichinsky EP, Haberkem CM, Neumayr L, et al: A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle ce ll disease. The Preoperative Transfusion in SickJe Cell Disease Study Group. N Engl J Med 333:206-213, 1995 8. AI-Salem AH, Nourallah H: Sequential endoscopic!laparoscopic manage ment of cholelithiasis and choledocholithiasis in children who have sickle cell di sease. J Pediarr Surg 32: 1432- 1435, 1997 9. Newman KD, Powell OM, Holcomb GW: The management of choledocholithi asis in children in the era of laparoscopic cholecystectomy. J Pediatr Surg 32: I I 16- 1119, 1997
10. Gholson CF, Grier JF, Ibach MB , et al: Sequential endoscopic! laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis. South Med J 88: 11311135,1995 II. Craigie JE, Ad ams DB, Byme TK, et al: Endoscopic electrohydraulic lithotripsy in the management of pancreatobili ary lithias is. Surg Endosc Ultrasound (ntervent Tech 12:405-407, 1998 12. Tagge EP, Tarnasky PR, Chandler J, et al: Multidisciplinary approach to the treatment of pediatric pancreaticobili ary di sorders. J Pedi atr Surg 32: 158-165, 1997 13. Hatley RM , Crist 0, Howell CG, et al: Laparoscopic cholecystectomy in children with sickle cell di sease. Am Surg 61 : 169-171 , 1995 14. Delatte S, Hebra A, Tagge EP, et al: Acute chest syndrome in the postoperative sickle cell pati ent. J Pediatr Surg (in press) 15. Schaffer RL, Brandt ML, Miltenburg OM, et al: Pedi atric chol elithiasis: Changing indication s for cholecystectomy. J Ped iatr Surg (in press) 16. AJ exander-Reindorf C, Nw aneri RU, Worrell RG , et al: The signifi cance of gallstones in children with sickle ce ll anemia. J Natl Med Assoc 82:645-650, 1990 17. Lagarde MC, Tunell WP: Surgery in patients with hemoglobin-S disease. J Pediatr Surg ] 3:605-607, 1978 18. Rambo WM , Reines HD : Elective cholecystectomy for the patient with sickle cell di sease and asymptomatic cholelithiasis. Am Surg 52:205-207, 1986
HE FIRST laparoscopic cholecystectomy was performed in 1987 in France by Dubois. Soon after its introduction, the procedure was widely adopted in both the United States and Europe for management of cholelithi.asis in adults. Pediatric surgeons were slower to embrace thi s new technique for a variety of reasons: (1) fewer patients with cholelithiasis, (2) space limitations in the pediatric abdomen, (3) the lack of pediatric-sized laparoscopic instruments, and (4) the need for accomplished surgeons to acquire new operating skills. Thus, initial series describing the outcome of laparoscopic cholecystectomy in children were quite small,I -3 with "larger" series having only 20 to 30 patients. 4 •5 However, a few institutions, including the Medical University of South Carolina, eventually acquired significant experience with laparoscopic cholecystectomy in children. We developed this experience·because of (1) an early commitment to laparoscopic techniques for children, (21 access to a large population of pediatric patients with sickle cel1 disease, and (3) the establishment of our Digestive Disease Center, with its wide referral base owing to its outstanding expertise in djagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). This report will attempt to highlight the rep0l1ed experience with pediatric laparoscopic cholecystectomy, intermingled with our personal experience.
T
PRESENTATION
Severa] investigators have commented that cholelithiasis is being recognized with increasing frequency in pediatric patients. 6 In Lugo-Vincente's 1997 study, 83 patients between 21 months and L8 years of age were identified. In his series, females (76%) with cJassic biliary symptoms predominated, with abnormal liver chemistry values, obesity, and elevated triglyceride levels From the Division of Pediatric Surgery, Medical Uni versity of South Carolina. Charlestoll. sc. Address reprint requests to Edward P. Tagge, MD, Pediatric Surgery, 900 MUSC Complex. Suite 633. Charleston, SC 29425. Copyright © 1998 by W.B. Saunders Company 1055-8586/98/0704-0008$08.00/0 202
comprising the most significant predisposing factors. Other investigators have noted that a significant minority of gallstones in children are idiopathic, whereas the majority are associated with the common predisposing factors for pediatlic cholelithiasis: chronic hemolysis, obesity, pregnancy and oral contraceptive use, total parenteral nutrition (TPN)-induced cholestasis, congenital heart disease and polycythemia, and ileal disease (eg, cystic fibrosis) or resection. In our series of 114 patients managed between December 1990 and October 1997, chronic hemolysis from sickle cell disease was the etiology for 83 patients (73 %) ; idiopathic stones was our next largest category. The diagnosis of cholelithiasis is made almost exclusively with ultrasonography, which is safe, relatively inexpensive, and usually painless. Until recently, the diagnosis of choledocholithiasis has been confirmed primarily by ERCP, although in a few cases ultrasonography has correctly identified common duct stones. Ultrasound evaluation more often provides clues that concomitant choledocholithiasis exists . However, because ERCP is an invasive procedure that usually requires general anesthesia (except in older pediatric patients), we are currently investigating the utility of magnetic resonance cholangiopancreatography (MRCP) to diagnose common duct stones. Most children with cholelithiasis have symptoms that have precipitated the diagnosis, and almost all investigators would agree that cholecystectomy is indicated in children with symptomatic cholelithiasis. As in adults, the management of either asymptomatic cholelithi asis or cholelithiasis with atypical symptoms (eg, the sickle cel1 patient with nonspecific abdominal pain) is more controversial. With accumulating data showing that chi1dren with comorbid factors (such as congenital heart disease or sickle cell anemia) have higher rates of morbidity and mortality associated with their cholelithiasis, such children are being referred more frequently by primary care physicians. That has been our experience in patients with sickle cell disease. Before December 1990, when we performed our first laparoscopic cholecystectomy, only one or two children with sickle cell anemia underwent open cholecystectomy each year, usually owing to complications of their disease. Since 1991, we have seen a marked increase in referral of sickle cell patients with cholelithiasis and a decrease in the acuity of their gallbladder disease. 4 Seminars in Pediatric Surgery, Vol 7, No 4 (November), 1998: pp 202-206
203
LAPAROSCOPIC BILIARY TRACT SURGERY
TECHNIQUE
Preoperative Management Preoperative management is an important aspect of all surgical procedures, especially for patients with sickJe cell disease. Initially, all sickle ce11 patients scheduled for operation underwent exchange transfusion to lower their hemoglobin S percentage to less than 30%. However, from 1990 to 1993, our patients with sickle ce11 disease were entered into a national preoperative transfusion study protocol, being randomized to either (A) exchange transfusion to raise the hemoglobin level to 10 mg% and decrease hemoglobin S to less than 30% or (B) simple transfusion to increase the hemoglobin level ~o to mg%, independent of the hemoglobin S percentage. The results of this study showed that a conservative transfusion regimen was as effective as an aggressive regimen in preventing perioperative complications in patients with sickle cell anemia, and also resulted in only half as many transfusion-associated complications. 7 All our subsequent patients with sickle cell disease have been managed using simple transfusion to increase the hemoglobin level to 10 mg%.
Operative Technique: Laparoscopic Cholecystectomy Initially the preparation for laparoscopic cholecystectomy included insertion of a Foley catheter and orogastric tube, in anticipation of the induction of pneumoperitoneum with use of a Veress needle. However, after our early experience, we began and have continued to use the Hasson open approach for placement of the umbilical trocar; subsequently we discontinued the practice of inserting a Foley catheter. Although initjany intraabdomina] pressure was maintained at about 15 mm Hg, our subsequent impression that high intraabdominal pressures caused increased postoperative abdominal pain has led us to reduce the pressure to as low as possible, usually less than 12 mm Hg. A 30° angled laparoscope is inserted through a 10-mm (or more recently, 5-mm) nondisposable umbiljcal trocar, and three additional 5-mm nondisposable trocars are placed under direct vision, their placement being individualized according to the patient's body habitus and previous surgical incisions. For infants and young children, for whom "instrument congestion" and very short working distances can be a problem, these . ports must be positioned as far from the right upper quadrant as possible. The left-upper-quadrant trocar is positioned between the xiphoid and umbilicus, to the left of the midline. Tills trocar, through which the main surgical dissection is performed, is positioned as high in the left upper quadrant as possible, to provide an improved angle and thus safer approach to the cystic duct and artery. Two additional trocars are placed on the right side of the abdomen, either in line with or below the
umbilicus, one in the midclavicular 1ine and one in the anterior axillary line. Most of our laparoscopic cholecystectomies have been initiated by intraoperative cholangiography, to determine the anatomy of the cystic duct as well as identify the presence of common duct stones. Cholangiography is performed via a 16-gauge through-the-needle Intracath (Becton-Dickinson , Sandy, UT), which is advanced through the abdominal wall and into the fundus of the gallbladder. Fluoroscopy is used to visualize filling of the gallbladder, cystic duct, common bile duct, and eventually the duodenum. Special care is taken to identify the course of the cystic duct and its junction with the common duct, to help decrease the possibility of common duct injury. The gallbladder is put on tension with ratcheted graspers placed through the right-sided trocar , driving the fttndus of the gallbladder over the liver while retracting the infundibulum laterally. Lateral retraction of the infundibulum is very important because superior retraction of the infundibulum has been identified as one of the technical maneuvers that predisposes to common bile duct injury. The cystic duct is isolated with great care, and its junction with the gallbladder is totally exposed using hook cautery. Three hemoclips are placed across the duct, which is then divided as close to the gallbladder as possible, leaving two clip on the cystic duct stump. In identical fashion, the cystic artery is identified and divided close to the gallbladder. The gal lbladder is dissected from the liver bed in retrograde fashion, and is removed through the umbilical incision under direct vision.
Operative Technique: Laparoscopic Common Duct Exploration Dependi.ng on the experience of the surgeon and the availability and skill of the therapeutic endoscopist, common duct stones can be handled via (1) open common bile duct exploration (CBDE), (2) postoperative ERCP, (3) intraoperative ERCP, or (4) laparoscopically. For surgeons who choose intraoperative or postoperative ERCP, placement of a small guide wire (0.035 in) through the cystic duct (secured by an endoloop) and into the duodenum may significantly decrease the likelihood of failure of the subsequent therapeutic ERCP. Laparoscopic common duct exploration can be performed in two ways: transcystically or via diTect choledochotomy. Transcystic CBDE is begun with a hemoclip pJaced across the junction of the cystic duct and gallbladder. A small incision is made in the cystic duct, which prov.ides access to the common duct. Using fluoroscopy, irrigation of the common duct and transcystic basket retrieval are attempted initially. If unsuccessful, cystic duct dilatation and choledochoscopy is attempted. Using
204
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a flexible choledochoscope, basket retrieval under direct visua1ization is tried, and, if unsuccessful, stone fragmentation using an electrohydrauJic lithotriptor can be performed. For the advanced laparoscopist, choledochotomy and direct stone removal can be performed if all else fails. This can be facilitated by placement of two retraction sutures on either side of the common duct, which are brought through the anterior abdominal wall for improved common duct exposure and stabilization (personal communication, G.W. Holcomb III). After laparoscopic choledochotomy, most investigators recommend placement of a T-tube if a sphincterotomy had not been performed previously. RESULTS
Laparoscopic Cholecystectomy From December 1990 through October 1997, laparoscopic cholecystectomy was attempted in 114 patients at our institution. The age range was 6 months to 23 years (mean, 12.3 years). Conversion to open cholecystectomy was required for only 3 patients (2.6%): one because of massive hepatomegaly, one owing to a very short cystic duct with multiple common duct stones, and the third because of the patient's small size (6 months old, early in our series). Intraoperative cholangiography showed unsuspected choledocholithiasis in seven patients (6%). Their management is detailed below. To date, no patient has suffered bile duct injury or required management of a biloma. The postoperative length of stay has averaged 2.5 days, despite the high percentage of patients with sickle cell disease and their comorbid conditions. Forty-eight percent of the patients were discharged by 24 hours postoperatively, and 80% were discharged within 48 hours.
Choledocholithiasis There are several algorithms for the management of choledocholithiasis in adults, based mainly on the timing of endoscopic retrograde cholangiopancreatography (ERCP) and the indications for open common duct exploration. Until recently, little had been written on the management of pediatric choledocholithiasis. Early reports addressing this issue in children, particularly those with sickle cel1 anemia known to be associated with a high incidence of choledocholithiasis, indicated that the sequential approach of ERCP with stone extraction followed by laparoscopic cholecystectomy was safe and effective. 8- IO For instance, Newman et aI, in a review of two pediatric surgical services, preoperatively identified 14 of 131 children (11 %) suspected of having common duct stones. 9 All had successful diagnostic ERCP, and eight children were noted to have common duct stones, all which were removed successfully using sphincterotomy or sphincter dilation. However, in six children
(43%) no stones were noted. Laparoscopic cholecystectomy was then performed a mean of 3.8 days after ERCP. In none of the eight children with common duct stones were retained stones noted. Of their remaining 117 children undergoing primary laparoscopic cholecystectomy, only one had an unsuspected common bile duct stone, which was treated successfully by laparoscopy. Because of our large experience with sickle cell disease in conjunction with a high-volume ERCP referral service at our Digestive Disease Center, we have had extensive experience with pediatric choledocholithiasis. Seven of our patients (6%) were noted to have unsuspected choledocholithiasis through routine intraoperative cholangiography. These patients were handled in a variety of ways. One child underwent open CBDE because of a very short cystic duct and many common duct stones. Two children underwent successful transcystic CBDE, using irrigation alone in one and stone fragmentation by EHL followed by irrigation in another. II In one child whose transcystic CBDE failed, postoperative ERCP with stone extraction was successful. Finally, because our therapeutic endoscopists are readily available, three children were able to have successful intraoperative ERCP with sphincterotomy and stone extraction. Seventeen additional patients suspected of having choledocholithiasis underwent ERCP, either preoperatively (n = 10) or after laparoscopic cholecystectomy (n = 7, with 5 of those patients referred to our Digestive Disease Center after having laparoscopic cholecystectomy at otherins6tutions).l2 AU patients had successful diagnostic ERCP, including a 6 month old. Ten children (59%) were noted to have common duct stones. All the stones were extracted endoscopically, including successful endoscopic removal of an impacted ampulJary stone after an open CBDE (at whkh time more than 100 stones had been removed). Based on these data, we recently altered our treatment aJgorithm for children with suspected choledocholithiasis. Before this review, we employed ERCP in a preoperative setting for any child suspected of having choledocholithiasis. However, three factors have led us to alter that algOl;thm: (1) the almost uniform success rate for both diagnostic and therapeutic ERCP, removing the onus to perform the procedure before laparoscopic cholecystectomy, (2) the unexpectedly high percentage (41 % in our series, 12 43% reported by Newman et al,9 62% noted by Gholson et al lO ) of normal ERCP findings in this preselected group of patients, which significantly increased cost and morbidity, without providing any clinical benefit, (3) our increasing ability to perform laparoscopic common duct explorations, either transcystically or via laparoscopic choledochotomy. Thus, we presently use the following algorithm for children with suspected choledocholithiasis. For the rare children who present with either
LAPAROSCOPIC BILIARY TRACT SURGERY
cholangitis or fulminant pancreatitis (suggestive of an impacted stone), we still employ preoperative ERCP with sphinterotomy (or sphincter dilation), stone removal, and internal stent placement. Those patients are discharged home, and return for their laparoscopic cholecystectomy and endoscopic stent removal several weeks later. The majority of our children, including those we suspect of having common duct stones, proceed directly to laparoscopic cholecystectomy with intraoperative cholangiography. If common duct stones are identified, transcystic CBDE is performed, with Japaroscopic choledochotomy reserved for select patients depending on the experience of the laparoscopist. If laparoscopic CBDE is unsuccessful, laparoscopic cholecystectomy is completed, and either intraoperative or postoperative ERCP is employed. Although we have had little experience with this new algorithm, we are hopeful that it will decrease both cost and morbidity by eliminating negative preoperative ERCP studies. Thus, ERCP would be reserved for common duct stones that are retained after laparoscopic cholecystectomy.
Complications There are little data in the literature regarding complications after pediatric laparoscopic cholecystectomy. In a report presented to the 42nd Annual International Congress of the British Association of Paediatric Surgeons in July 1995 (unpublished), we critically reviewed the complications that occun'ed in our first 50 patients, treated from December 1990 through October 1994. Most of these patients had sickle cell disease, and their complications were more often related to their comorbid disease than to the Japaroscopic cholecystectomy. We divided these patients into three groups, based on the timing of their complication (immediately, within 30 days of laparoscopic cholecystectomy, more than 30 days after laparoscopic cholecystectomy). Seven patients experienced complications during their initial hospital stay. Two patients had significant perioperative hemorrhage that required transfusion. One of them had significant bleeding from a cystic artery injury that eventual1y was controlled during the laparoscopic cholecystectomy. In the other child, significant abdominal pain and anemia developed during the first 24 hours postoperatively. Laboratory results showed not only a decreasing hematocrit but also a prothrombin time of 16.4 seconds (normal, ' < 11.4 seconds). Despite resuscitation with fresh frozen plasma, reexploration was required, whereupon a large hematoma in the liver bed was found, with no obvious bleeding source. The experience with this child, in conjunction with a report by Hatley et al,13 subsequently led us to perform routine preoperative screening of coagulation in all patients with sickle cell disease. Four patients experienced either pneumonia or significant
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atelectasis with hypoxia, which required supplemental oxygen, chest physiotherapy, and a short course of antibiotics. Currently known as acute chest syndrome, this constellation of symptoms continues to be an important postoperative problem for patients with sickle cell disease. 14 One child had ventricular tachycardia immediately after surgery, which necessitated a 5-day stay in the intensive care unit and a 13-day overall postoperative stay. A child with acute lymphoblastic leukemia and Salmonella cholecystitis developed pseudomembranous colitis and was discharged 36 days after the laparoscopic cholecystectomy. Three patients, all with sickle cell disease, had complications within 30 days of the laparoscopic cholecystectomy, but after their initial discharge. All three returned complaining of abdominal pain different from their usual vasoocclusive pain. All three patients were readmitted to the ho&pital and underwent abdominal radiography, ultrasonography, and nuclear medicine imaging of their biliary tracts. No bile duct leaks, fluid collections, or pneumoperitoneum were identified. The patients were discharged within 4 days and had spontaneous resolution of their symptoms. Seven patients returned with complications after the 3~-day perioperative pedod. Five patients, all with sickle cell disease, returned with abdominal pain. However, this time the pain was similar to that experienced preoperatively, which had precipitated the laparoscopic cholecystectomy. All episodes responded to intravenous fluid hydration and parenteral analgesia. One child returned with obstructive jaundice and pancreatitis owing to a stone impacted at the ampuJ)a of Vater, which was removed successful1y by ERCP. The remaining chj]d, who had cystic fibrosis, returned with a symptomatic hernia in the left-upper-quadrant trocar site. These complications had a major impact on postoperative stay (10.9 days for those with compUcations v ] .6 days for those without complications), and thus overall cost, emphasizing the importance of these previou ly underappreciated problems. The surgeon and the patient's family must understand that laparoscopic cholecystectomy remains a major abdominal intervention with significant attendant risks, particularly for children who have additional comorbid factors. Fin aJI y, Schaffer et al from the Baylor CoJlege of Medicine pointed out th apparently undenecognized need for emergency cholecystectomy among the pediatric population. IS Of their 124 patients treated between 1980 and ] 996,25% of cholecystectomies were pelformed urgently, and those patients had a significantly higher risk of postoperative complications, including death. Their three deaths involved patients with congenital heart disease, thus making congenital heart disease an independent risk factor for gallstonerelated mortality. This study, and others noting an
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increased risk of complications in sickle cell patients who undergo emergency gallbladder management, 16- 18 suggest that earlier elective cholecystectomy might be appropriate for select children with comorbid diseases. Thus,
balancing the risklbenefit ratio of delayed versus early surgery for children with cholelithiasis and significant comorbid conditions will continue to be a challenge for both the primary care physician and pediatric surgeon.
REFERENCES L Dav idoff AM, Branum GO, Murray EA, et al: The technique of laparoscopic cholecystectomy in children. Ann Surg 2 15 : 186- 191, 1992 2. Moir CR, Donohue JH, van Heerden JA: Laparoscopic cholecystectomy in children: Initial ex peri ence and reco mmendations. J Pediatr Surg 27: 1066- 1068, 1992 3. Newman KD, Marmon LM, Attorri R, et al: Laparoscopic cholecystectomy in pedi atric pati ents. J Pediatr Surg 26: 1.184-1185, 199 1 4. Tagge E P, Otherse n HB, Jackson SM, et al: Impact of laparoscopic chol ecystectomy on the management of cholelithiasis in children with sickJe cell disease. J Pedi atr Surg 29:209-2 12, 1994 5. Holcomb GW, Sharp KW, Neblett WW, et al: Laparoscopic cholecystectomy in infants and children: Modification s and cost analysis. J Pedi alr Surg 29:900-904, 1994 6. Lugo-Vicente HL: Trends in management of gallbl adder di sorders in children. Pediao' Surg Jnt 12:348-352, 1997 7. Vichinsky EP, Haberkem CM, Neumayr L, et al: A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle ce ll disease. The Preoperative Transfusion in SickJe Cell Disease Study Group. N Engl J Med 333:206-213, 1995 8. AI-Salem AH, Nourallah H: Sequential endoscopic!laparoscopic manage ment of cholelithiasis and choledocholithiasis in children who have sickle cell di sease. J Pediarr Surg 32: 1432- 1435, 1997 9. Newman KD, Powell OM, Holcomb GW: The management of choledocholithi asis in children in the era of laparoscopic cholecystectomy. J Pediatr Surg 32: I I 16- 1119, 1997
10. Gholson CF, Grier JF, Ibach MB , et al: Sequential endoscopic! laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis. South Med J 88: 11311135,1995 II. Craigie JE, Ad ams DB, Byme TK, et al: Endoscopic electrohydraulic lithotripsy in the management of pancreatobili ary lithias is. Surg Endosc Ultrasound (ntervent Tech 12:405-407, 1998 12. Tagge EP, Tarnasky PR, Chandler J, et al: Multidisciplinary approach to the treatment of pediatric pancreaticobili ary di sorders. J Pedi atr Surg 32: 158-165, 1997 13. Hatley RM , Crist 0, Howell CG, et al: Laparoscopic cholecystectomy in children with sickle cell di sease. Am Surg 61 : 169-171 , 1995 14. Delatte S, Hebra A, Tagge EP, et al: Acute chest syndrome in the postoperative sickle cell pati ent. J Pediatr Surg (in press) 15. Schaffer RL, Brandt ML, Miltenburg OM, et al: Pedi atric chol elithiasis: Changing indication s for cholecystectomy. J Ped iatr Surg (in press) 16. AJ exander-Reindorf C, Nw aneri RU, Worrell RG , et al: The signifi cance of gallstones in children with sickle ce ll anemia. J Natl Med Assoc 82:645-650, 1990 17. Lagarde MC, Tunell WP: Surgery in patients with hemoglobin-S disease. J Pediatr Surg ] 3:605-607, 1978 18. Rambo WM , Reines HD : Elective cholecystectomy for the patient with sickle cell di sease and asymptomatic cholelithiasis. Am Surg 52:205-207, 1986