THE ”ACUTE” SCROTUM

Report
Gallbladder Disease in Infants
and Children
2011 ISW Meeting
George W. Holcomb III, MD, MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, Missouri
Ann Surg 191:626-635, 1980
Biliary Disease
• Gallstones
• Hemolytic disease
• Non-hemolytic disease
• Biliary dyskinesia
• Acalculous disease
Risk Factors for Cholelithiasis in
Infants and Children
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
Biliary Dyskinesia
• Symptomatic biliary colic w/o stones
• Reduced GBEF and pain with CCK
stimulation
• Has become the most common reason for
cholecystectomy in many U.S. centers
• IU study – 37 pts – 71% resolution of
symptoms

GBEF < 15%
successful resolution of
symptoms (O.R. – 8.00)
• Chronic cholecystitis seen on histological
examination of many specimens
Symptoms
• Epigastric/RUQ pain
• Nausea/vomiting
• Fatty food intolerance
• Painless jaundice
• Pancreatitis
Imaging Studies
• Ultrasound
• Radionucleide
gallbladder
emptying study
(with CCK)
• Hepatobiliary scan
Complicated Cholelithiasis
• Acute
cholecystitis
• Jaundice
• Pancreatitis
Timing of Cholecystectomy
• Non-complicated disease – 0 – 14 days
• Complicated disease
•
•
•
Jaundice – following work-up
Cholecystitis – 2-4 days
Pancreatitis – once resolved
When to Suspect
Choledocholithiasis?
• Elevated bilirubin (jaundice)
• Elevated lipase, amylase (pancreatitis)
• Dilated CBD or stone(s) in CBD on
ultrasound
MANAGEMENT OF
SUSPECTED
CHOLEDOCHOLITHIASIS
Management Options
• Pre-op ERCP, sphincterotomy, stone
extraction
• Laparoscopic or open CBD
exploration at time of
cholecystectomy
• Post-op ERCP, sphincterotomy,
stone extraction (adults)
Factors
• Surgeon’s experience with
laparoscopic CBD exploration
• Availability of an endoscopist to
perform ERCP in children
14/131 suspected choledocholithiasis
J Pediatr Surg 32:1116-1119, 1997
Algorithm
Suspected Choledocholithiasis
Why ERCP First?
• Surgeon knows at time of
laparoscopic cholecystectomy
whether CBD (laparoscopic or open)
exploration is needed
• Potentially avoids a third anesthesia
and operation
Disadvantage
A number of ERCPs will be
performed in patients that do not
have CBD stones
IS ROUTINE
CHOLANGIOGRAPHY
NEEDED?
Cholangiography
• 1990-1995: Reasonable to perform
cholangiography to become facile
with technique
• 2011: Most surgeons have become
facile with this technique
Cholangiography
• To evaluate for CBD stones
• To define anatomy
My Approach
• Reserve cholangiography for cases
where anatomy is unclear
• Use ultrasound pre-operatively to
define CBD involvement
Pre-operative Ultrasound
• Prior to laparoscopic cholecystectomy
• Confirm stones, evaluate for CBD
dilation or stones
• Cost-effective strategy
Financial analysis of preoperative ultrasonography versus
intraoperative cholangiography for detection of choledocholithiasis at
Children's’ Mercy Hospital, Kansas City MO
2008
Immediate Pre-op
Evaluation with US
Ultrasound study
(including radiologist
fee)
Charges ($)
Intraoperative
Cholangiography
Charges ($)
307.67 15-minutes OR time
1500.00
C-Arm with
radiologist fee
TOTAL
365.41
Sterile drape for CArm
20.00
Cholangiocatheter
83.50
Contrast for
cholangiogram
40.00
$307.67 TOTAL
$2008.91
Cholangiography
Cystic Duct
Cannulation
Kumar Clamp
Technique
Kumar Clamp Technique
Surg Endosc 8:927-930, 1994
Where do I place the
instruments/ports for a
laparoscopic
cholecystectomy?
Port Placement
Stab Incision Technique
• 2 cannulas
• 2 stab incisions
Key Steps in Operation
1. Begin dissection high on gallbladder to expose
triangle of Calot
2. 900 orientation cystic and common ducts
Critical View of Safety
What Do I Do If I Cut
the Common Bile Duct?
Options
• Ligate duct
•
wait for it to enlarge
• transfer to experienced biliary surgeon
• Repair laparoscopically
• Repair open
•
interrupted sutures
• T – tube
• choledochojejunostomy at second operation
CMH Experience
2000 - 2006
• 224 Pts
(12.9 yrs, 58.3 kg)
• Indication
• Symptomatic gallstones
•
•
•
•
Biliary dyskinesia
Gallstone pancreatitis
Gallstones/splenectomy
Calculous cholecystitis
• Other
166
35
7
6
5
4
IPEG, 2007
J Laparoendosc Adv Surg Tech 18:127-130, 2008
CMH Experience
2000-2006
• Mean operative time
•
77 min
Cholangiograms –
Intraoperatively
 Stones
 Cleared intraop
 Cleared postop
38
Preoperatively (ERCP)
 Stones found
17
• Ductal injuries
9
5
4
8
0
IPEG, 2007
J Laparoendosc Adv Surg Tech 18:127-130, 2008
SSULS Cholecystectomy
SSULS Cholecystectomy
More Difficult Operation
SSULS Cholecystectomy
Please use this link if you experience problems viewing the video above.
SSULS Cholecystectomy
Adults
•
•
•
•
•
•
•
Can be performed safely but is more challenging
Longer operating times (75 – 120 min)
Difficulty with triangulation of instruments
Additional ports/instruments - 10-30% cases
Sutures thru infundibulum or fundus for retraction
Slight incidence injury CBD (0.7% vs 0.2%)
Selected patients



Relatively thin patient
Non-inflamed gallbladder
Intra-op cholangiogram can be difficult
SSULS Cholecystectomy
Pediatrics
• CH-A: 25 cases
Mean op time – 73 min (30-122)
Additional instrument/port 22 pts (88%)
Nougues CP et al. JLAST 20:493-496, 2009
• CH-LA: 24 cases
Mean op time – 97 min (65-145)
Addt’l port – 2 pts (8%)
Emami CN et al. Am Surg 76:1047-1049,2010
SSULS Cholecystectomy
Pediatrics
CMH: 24 cases
Mean op time – 73 min
Conversion to 4-port – 2 pts (8%)
Garey CL et al
J Pediatr Surg 46:904-907, 2011
SSULS Cholecystectomy
Pediatrics
• Safe
• Effective
• Is it better than the 4-port technique?
CMH Prospective Randomized
Trial
• Power analysis - 60 patients (59 to date)
• Primary outcome variable - operative time
Secondary Outcome Variables
• Complications
• Postoperative pain
• Cosmesis
• Infection rate
• Operative charges
QUESTIONS
www.cmhmis.com

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