Management of the Pediatric Patient with Choledocholithiasis in an Era of Advanced Minimally Invasive Techniques

Abstract

Background:

The treatment algorithm for children with suspected choledocholithiasis is not well established because the breadth of minimally invasive surgery and endoscopic techniques continues to evolve. We reviewed our experience with common bile duct explorations (CBDEs) in order to detail the techniques used and describe the rate of complications of laparoscopic CBDE in children.

Subjects and Methods:

As part of an Institutional Review Board–approved study, medical records were reviewed for all patients, 1 month to 21 years of age, undergoing a cholecystectomy at a large tertiary-care children's hospital over an 11-year period. Those undergoing an intraoperative cholangiogram (IOC) were documented, and operative reports and postoperative records were examined.

Results:

Over 11 years, 464 cholecystectomies were performed, and an IOC was attempted on 174 patients with a 97% success rate (n=168). Of the patients who underwent a cholangiogram, 30% (n=52) had an obstructing stone. Laparoscopic CBDE was attempted in 50 patients with a conversion rate of 8%. Postoperatively, 3 CBDE patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for the following reasons: retained stone (n=1), persistent hyperbilirubinemia (n=1), and bile leak (n=1).

Conclusions:

Laparoscopic CBDE is a safe initial approach to choledocholethiasis and is successful at relieving the obstruction the majority of the time. The authors conclude that in situations where there is limited availability of ERCP, laparoscopic CBDE should be considered as a first step in the management of obstructive choledocholethiasis.

Introduction

Although more frequently encountered in the adult population, choledocholithiasis does occur in children. Open common bile duct (CBD) exploration (CBDE) has been challenged as the standard of care as minimally invasive surgery and endoscopic techniques and equipment have evolved; however, the treatment algorithm for pediatric patients with choledocholithasis continues to be debated.^1–3

Patients predisposed toward hemolysis (e.g., sickle cell disease, hereditary spherocytosis) are known to have a higher frequency of cholelithiasis and choledocholithiasis.^4–6 Likewise, there are regional discrepancies in the disease prevalence within the United States and internationally. Given the location of our tertiary-care children's hospital and the increased frequency of sickle cell anemia in the southeast United States, we hypothesized that the incidence of choledocholithiasis would be relatively high in our surgical practice. We aimed to review our experience with CBDEs over the past decade in order to detail the techniques used and describe the rate of complications of laparoscopic CBDE in children.

Subjects and Methods

Patients and study design

As a part of an Institutional Review Board–approved study, medical records were reviewed for all patients, 1 month to 21 years of age, undergoing a cholecystectomy at a large tertiary-care children's hospital over an 11-year period. Those undergoing an intraoperative cholangiogram (IOC) were documented, and operative reports and postoperative records were examined. The decision to perform a cholangiogram or a CBDE was based on the laboratory values, preoperative and intraoperative imaging, and clinical judgment of the surgeon. Postoperative management, including the decision of when to obtain laboratory values, was directed by the operating surgeon. Generally speaking, postoperative laboratory values were obtained for patients who had a positive IOC and underwent CBDE.

All data were analyzed using SPSS software (SPSS Inc., Chicago, IL) and are presented as mean±standard deviation (SD) values unless otherwise noted where a P value of<.05 was deemed as statistically significant.

Surgical techniques

Cholecystectomy

A standard four-trocar approach to laparoscopic cholecystectomy is taken, with a trocar in the umbilicus, a trocar in the subxiphoid region, and two trocars in the right upper quadrant. Once the infundibulum has been cleared of its investing peritoneum, the cystic artery and cystic duct are identified entering the gallbladder. The gallbladder is freed off of the cystic plate partially, allowing a view through the window formed among the liver, gallbladder, and cystic duct. Once this “critical view of safety” is obtained, the cystic artery is divided with either diathermy or between clips.

IOC

A 5-mm titanium clip is applied to the cystic duct near the infundibulum, and a ductotomy is created with scissors. A 16-gauge Angiocath™ (BD, Franklin Lakes, NJ) is threaded obliquely through the right upper quadrant, providing a direct approach to the open cystic duct. A 0.035-inch hydrophilic wire is threaded into the peritoneum, followed by a 5 French angled-tip Kompe catheter. The catheter is threaded into the cystic duct, and the wire is passed distally. The catheter is advanced over the wire using a Seldinger technique, and another 5-mm clip is applied across the cystic duct, pinning the catheter in place. The wire inside prevents the lumen of the catheter from occluding, and the wire is now withdrawn. A standard cholangiogram is obtained. The presence of a filling defect within the common bile duct signifies the presence of a stone and therefore warrants a ductal exploration.

Laparoscopic CBDE

Intravenous glucagon (1 mg) is administered by the anesthesiologist, and a forceful flush of the duct with saline can be taken as a first step. Repeat cholangiography showing a retained stone will next require passage of a zero-tip wire basket, using the Kompe catheter as a conduit. The position of the basket can be determined by fluoroscopy but can also be determined by noting the depth at which increased resistance is met. The basket is opened, gently brushed back and forth several times, and then closed gently. The entire apparatus is removed together, with the presence of stones or debris noted as the wire is withdrawn from the ductotomy. Flushes with normal saline in between, followed by repeated cholangiograms, will determine the presence/absence of a retained stone. An alternative approach uses a Fogarty catheter. The catheter is placed through the cystic ductotomy and passed beyond the stone in the CBD with the balloon deflated. The balloon is slowly inflated until slight resistance is met and then gradually withdrawn from the CBD, extracting the obstructing stone as the catheter is removed. A Pruitt^® irrigating/occluding catheter (LeMaitre Vascular Inc., Burlington, MA) offers the advantage of a channel for concurrent contrast injection.

If a stone persists in the distal common duct, choledochoscopy can be performed. Usually, the cystic duct will allow passage of the flexible choledochoscope, but occasionally a ductotomy extending onto the common duct is performed with scissors. The choledochoscope is passed through an additional trocar placed in the right upper quadrant. It can be guided into the cystic duct and then navigated independently once inside. It is essential to have a continuous flow of saline through the working channel to keep a clear view. Once the distal common duct is visualized and the stone is in view, a basket can be passed via the working channel, and the stone is captured under direct vision. Once again, the entire apparatus is withdrawn.

A completion cholangiogram is performed to demonstrate absence of filling defects. The cystic duct is then closed with either titanium clips or an endoloop. In the event that the common duct was opened, it is closed with absorbable, monofilament suture.

An alternative treatment strategy in the setting of a small duct that precludes passage of the choledochoscope would be use of postoperative endoscopic retrograde cholangiopancreatography (ERCP). Recognizing that an unsuccessful stone extraction with ERCP is a possibility, repeat surgical exploration may be required.

Results

Between January 2000 and December 2011, 464 cholecystectomies were performed at our institution. Based on surgeon preference, an IOC was attempted on 174 patients at the time of cholecystectomy with a 97% completion rate (n=168). Indications for cholecystectomy in patients undergoing IOC included symptomatic cholelithiasis (n=60), choledocholithiasis (n=49), gallstone pancreatitis (n=33), acute cholecystitis (n=12), chronic cholecystitis (n=12), and acalculus cholecystitis (n=8). The median age for patients undergoing an IOC was 14.2 years (range, 3 months–20 years) with an average body mass index percentage of 55.4 (SD 32.7). The median length of stay postoperatively for patients who had an IOC was 2 days (range, 1–32 days).

The overall rate of choledocholithiasis for all patients undergoing a cholecystectomy with IOC was 30% (n=52). CBDE was successfully performed 98% of the time (n=51). Laparoscopic CBDE was attempted in 50 patients and successfully completed in 46, with a conversion rate of 8%. Based on surgeon preference, 2 patients were treated with an open CBDE. Laparoscopic and open CBDEs were performed with wires, ureteral baskets, and balloon catheters with and without the aid of a choledochoscope. It is not surprising that the length of surgery for patients who underwent a CBDE was significantly longer than the time required for a laparoscopic cholecystectomy with IOC (P=.0001). The median postoperative length of stay for patients who had a CBDE was 3 days (range, 1–15 days). This was statistically longer than the length of stay for patients with a negative IOC (P=.001).

CBDE frequently required a combination of tools successfully clear the biliary obstruction. The tool that most frequently cleared the CBD in this series was the no-tip wire basket. A summary of the final technique used to clear the CBD can be seen on Figure 1.

FIG. 1.

Final technique used to successfully clear the common bile duct (CBD) for patient who underwent CBD exploration. ERCP, endoscopic retrograde cholangiopancreatography.

A subset analysis was performed looking at patients with a history of hemolytic anemia. A history of sickle cell disease was identified in 35% of the patients (n=63) who underwent cholecystectomy and IOC, and 25% of those patients (n=16) underwent CBDE for an obstructing stone. The average length of surgery and postoperative length of stay for patients with sickle cell disease who underwent CBDE were comparable to values for non–sickle cell patients who required CBDE (P=.48 and P=.27, respectively). The average body mass index percentage for patients with sickle cell disease who underwent a CBDE was 40.4 (SD 27.8), which is significantly lower than the BMI percentage of non–sickle cell patients who required the same procedure (P=.001). A summary of all patient characteristics can be found in Table 1. Seven of the 174 patients who had an attempted IOC (4%) had a diagnosis of spherocytosis, and 4 of those 7 (57%) underwent CBDE for a positive IOC. The rate of choledocholithiasis in patients with sickle cell anemia (25%) and spherocytosis (57%) did not differ significantly compared with those who did not have a hemolytic anemia (30%) (P=.39 and P=.19, respectively).

Table 1.

Comparison of Patient Demographics and Outcomes

Patients, procedure	Age (years) at surgery (range)	BMI percentage (SD)	P	Length of surgery (minutes) (SD)	P	Median postoperative length of stay (days) (range)	P
All IOC (n=174)
No CDBE (n=122)	13.3 (3 months–19.7 years)	51.6 (33.3)		91.4 (41)		2 (1–36)
CBDE (n=52)	14 (4 months–20 years)	61.5 (31.2)		190 (91)	.0001	3 (1–15)	.001
Non–sickle cell (n=111)
No CBDE (n=86)	15 (3 months–20 years)	57.8 (33.7)		89.8 (43)		1 (1–36)
CBDE (n=36)	14.7 (4 months–20 years)	72.7 (27.5)		201.8 (98)		2.5 (1–15)
Sickle cell (n=63)
No CBDE (n=47)	12 (2.7 months–19.7 years)	34 (24.9)		93.9 (40)		2 (1–11)
CBDE (n=16)	13.1 (2.9 months–17.4 years)	40.4 (27.8)	.019^a	163.3 (68)	.0001	3 (2–5)	.012

This is a comparison of patients with sickle cell who had a common bile duct exploration (CBDE) with non–sickle cell patients who had a CBDE.

BMI, body mass index; IOC, intraoperative cholangiogram; SD, standard deviation.

In order to address the potential selection bias of this retrospective study, we performed a subset analysis of one surgeon within our practice who universally performs an IOC on all cholecystectomies. This individual surgeon performed 90 cholecystectomies during the study period, and 100% of the patients had an attempted IOC. The rationale for routine cholangiography is demonstration of biliary anatomy, rather than detection of asymptomatic stones. Within this subset analysis, 17.7% (n=16) required a CBDE for an obstructing stone seen during the IOC. This is significantly lower than the rate of positive IOC seen in the larger cohort (P=.0004). Within this one surgeon's patient population, one-third (n=30) of the patients had sickle cell disease, of whom 20% (n=6) required CBDE. There was no statistical difference in the rate of choledocholithiasis between those patients with sickle cell and those without (P=.75).

Within this series there were several complications related to the IOC and the CBDE. The IOC was abandoned because of inflammation of the cystic duct and inability to pass the cholangiocatheter in 6 patients (3%). Additional complications noted in patients with negative IOC include an umbilical port-site hernia at 6 months after surgery (n=1), postoperative bleeding requiring a transfusion of 1 unit of packed red blood cells (n=1), upper gastrointestinal bleeding requiring transfusion of 1 unit of red blood cells (n=1), pancreatic duct stone requiring ERCP with stent placement (n=1), re-admission for hyperbilirubinemia/jaundice with normal magnetic resonance cholangiopancreatography (n=2), and subarachnoid hemorrhage on postoperative Day 2 (n=1). Laparoscopic CBDE was attempted in 50 patients, and 4 patients were converted to an open laparotomy. Cited reasons for conversion include perforation of the cystic duct (n=2) and inability to pass a catheter beyond the impacted stone (n=2). Three patients with a positive IOC who were treated with CBDE required ERCP during the immediate postoperative period. The indications for ERCP included an impacted stone (n=1), persistent hyperbilirubinemia (n=1), and bile leak (n=1). A summary of all complications for CBDE patients can be found in Table 2.

Table 2.

Complications (Intraoperative and Postoperative) for Patients Who Underwent Common Bile Duct Exploration

	Comorbidities	Complication	Treatment
Patient 1		Perforated cystic duct	Converted to laparotomy, unable to clear the duct with manual extraction. ERCP with sphincterotomy on postoperative Day 14
Patient 2		Perforated cystic duct	Converted to laparotomy. Cystic duct repaired and common bile duct successfully cleared
Patient 3	Sickle cell	Unable to pass choledochoscope	Converted to laparotomy with manual extraction of CBD stone
Patient 4		Unable to pass catheter or wire into CBD	Converted to laparotomy with manual extraction of CBD stone
Patient 5		Persistent abdominal pain, bile leak seen on HIDA	ERCP with stent placement on postoperative Day 7
Patient 6		Persistent jaundice	Normal ERCP on postoperative Day 4
Patient 7	Spherocytosis	Re-admitted on postoperative Day 7 with nausea and vomiting	Normal MRCP, resolved without intervention

CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; HIDA, hepatobiliary iminodiacetic acid; MRCP, magnetic resonance cholangiopancreatography.

Discussion

Choledocholithiasis occurs within the pediatric patient population at a rate that is regionally variable. CBDE has been described as an effective technique for management of CBD obstruction.^1,7,8 In this large patient series we have demonstrated that laparoscopic CBDE is an acceptably safe and successful approach for surgical management of biliary stone obstruction in children. Additionally, we have described a systematic approach to performing a laparoscopic CBDE in children using a variety of instruments and techniques to clear the CBD of impacted stones. Using this approach we have been able to successfully clear the duct 98% of the time. This was done with a laparoscopic approach in 92% of the cases.

ERCP is a well-described technique that can be used to clear the CBD in situations of choledocholithiasis and has been suggested as an alternative treatment algorithm.⁹ The success rate of ERCP, defined as successfully cannulating the ampula, ranges between 89% and 97%.^10,11 In the hands of a skilled endoscopist, the estimated complication rate for ERCP in children is 3%–5%.^11,12 The most frequently described complication is post-ERCP pancreatitis.

Within this series, the rates of successful CBDE and postoperative complications are similar to the rates that have been published for ERCP in children. Bansal et al.¹³ reached similar conclusions in their small randomized clinical trials comparing CBDE during laparoscopic cholecystectomy versus ERCP followed by laparoscopic cholecystectomy in adults. The primary advantage of a combined laparoscopic cholecystectomy/IOC with CBDE is that both goals of clearing the CBD and removing the gallbladder can be accomplished with a single procedure. This limits the number of times the patient is exposed to general anesthesia. Likewise, the CBDE is only performed on patients with a documented obstructing stone, thus preventing unnecessary instrumentation. An additional argument against a two-staged approach to managing choledocholithasis is the potential for recurrent obstructing stones after ERCP and before cholecystectomy. In one large series of adult patients with choledocolithiasis, the incidence of persistent choledocolithiasis was 13% for patients managed with ERCP followed by laparoscopic cholecystectomy.¹⁴ The conclusion of these authors was that IOC should be routinely performed on patients undergoing laparoscopic cholecystectomy after ERCP for CBD stones.

Within this cohort of patients, 4 patients required conversion to laparotomy after unsuccessful laparoscopic CBDE. In retrospect, an interim use of ERCP may have prevented the laparotomy and should be considered a branch of the treatment algorithm before committing the patient to an open procedure. As mentioned, feasibility of this as an option will depend on institutional capabilities and patient size.

One weakness of this retrospective study is that the decision to perform an IOC was a result of the personal decision on the surgeon's behalf. This limits the authors from being able to comment on the true incidence of a positive IOC. We attempted to address this by performing a subset analysis of a single surgeon within the group who routinely performs IOC on all cholecystectomy patients. It is not surprising that the incidence of choledocholithiasis for this subset was 17.7%, which is significantly lower than the incidence of positive IOC in the larger cohort. It is interesting, however, that the incidence of positive IOC for patients with sickle cell disease was similar between the subset analysis and the larger cohort. This suggests that although there was a selection bias for who received an IOC, the incidence of finding choledocholithiasis in patients undergoing cholecystectomy is similar between patients with hemolytic disease and those without. The body mass index data on patients requiring laparoscopic CBDE reinforces the notion that stone disease in the hemolytic anemia population is more likely related to pigment stones than cholesterol or mixed stones.

Based on these data, we recommend that the decision to perform an IOC should be determined based on clinical suspicion for choledocholithiasis (including increased total bilirubin level, elevated lipase activity, or dilation of the CBD) rather than a history of hemolytic anemia alone. In the majority of institutions, regardless of age, ERCP is the current first-line therapy, reserving CBDE for failure of ERCP. However, there are institutions where pediatric ERCP is not readily available. In these situations, laparoscopic CBDE can be considered as a first step in the management of obstructive choledocholethiasis.

Footnotes

Disclosure Statement

No competing financial interests exist.

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