More Is Less: The Advantages of Performing Concurrent Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography for Pediatric Choledocholithiasis

Abstract

Introduction:

Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are standard of care for pediatric choledocholithiasis. Patients typically undergo separate procedures during hospitalization. Collaboration between surgical and gastroenterology services led to performance of both procedures concurrently during one anesthetic. We hypothesized that concurrent procedures would reduce costs without increasing complications as compared with separate procedures.

Materials and Methods:

We evaluated patients admitted to our institution from 2013 to 2018 with choledocholithiasis who underwent both ERCP and LC during the same admission. Fourteen patients underwent both procedures during concurrent anesthetic. Forty-two patients who underwent LC and ERCP under separate anesthetics were randomly selected to perform a 3:1 matched case–control study. Demographic and clinical data were collected, including imaging and laboratory findings, outcomes, and costs. Comparative analysis was completed with Fisher's exact and Mann–Whitney U tests.

Results:

On presentation, there was no difference in common bile duct size, total bilirubin, or white blood cell count between the concurrent and separate procedure cohorts. Significantly, there was no difference in total length of anesthesia (117.9 ± 40 minutes versus 119.6 ± 52 minutes, P = .747). There were also no differences in complications, emergency department visits, or readmissions. Patients who underwent concurrent procedures had significantly lower total cost of stay ($45,597 ± 11,513 versus $61,008 ± 17,960, P = .006).

Conclusions:

In pediatric patients with choledocholithiasis, performing LC and ERCP may be performed concurrently during one anesthetic, which decreases costs without increasing in anesthesia time or complications.

Introduction

The incidence of cholelithiasis and ensuing laparoscopic cholecystectomy (LC) is increasing in patients <18 years.¹ This is at least partially related to rising childhood obesity rates, with ∼17% of children in the United States classified as obese.² Obese children are more likely to suffer from cholelithiasis with gallstones seen 3.1 times more frequently in boys with obesity and 7.7 times more frequently in girls with obesity.³ As the rates of pediatric biliary disease increase, children are subsequently at higher risk for complicated gallbladder disease. Adult literature estimates that between 4% and 20% of patients with gallstone-related disease present with choledocholithiasis.⁴ Pediatric patients appear to be at even higher risk, with up to 30% showing signs of obstruction at preoperative workup.^5–7

Currently, the standard treatment for choledocholithiasis in children is an LC with either a pre- or postoperative endoscopic retrograde cholangiopancreatography (ERCP). This treatment plan exposes children to two separate procedures and the accompanying anesthesia inductions. Studies have demonstrated that multiple exposures to anesthesia in childhood are associated with development of learning disabilities and decreased academic performance.^8,9 An alternative to separate procedures for LC and ERCP would be to perform both procedures concurrently during the same anesthetic. Adult literature established that LC with concurrent ERCP is not associated with increased complications when compared with two separate procedures.^10–12

With pediatric cholelithiasis and complicated biliary disease on the rise, combined with the need for judicious anesthesia exposure in children, we hypothesized that concurrent LC and ERCP could be performed in pediatric patients with choledocholithiasis without an increase in postoperative complications.

Materials and Methods

Surgical practices

This study was carried out at a tertiary pediatric hospital. There are 12 pediatric surgeons and 2 pediatric gastroenterologists performing advanced endoscopy. The surgical service is consulted by the emergency department (ED) to evaluate patients with potential choledocholithiasis, who are typically admitted to the gastroenterology service if the diagnosis is confirmed by the surgical team. The standard treatment for patients with choledocholithiasis is ERCP followed by LC during the same admission. In 2016, we changed our practice to coordinate with the gastroenterology service to offer these procedures during a combined anesthetic. The decision to offer concurrent procedures is left to the judgment and preference of the attending surgeon and endoscopist as well as available timing of both teams. Although it is our goal to offer both procedures under a concurrent anesthetic, if coordination between services cannot be achieved, separate procedures are undertaken.

Currently, we offer all patients with choledocholithiasis a concurrent procedure, and the main limitation to consistent execution of this plan is availability of advanced endoscopists. We do not routinely perform intraoperative cholangiogram. With regard to laparoscopic common bile duct exploration (CBDE), we preferentially utilize endoscopic approaches due to a strong collaborative relationship with the pediatric advanced endoscopists at our institution. Currently, our practices are changing to increase laparoscopic CBDE implementation. Postoperatively, patients are observed in the hospital to monitor diet toleration and general recovery. The purpose of this study was to compare patients who received separate ERCP and LC with those who underwent these procedures concurrently during one anesthetic.

Patient selection and variables

After institutional review board (IRB) approval, all patients preoperatively diagnosed with choledocholithiasis based on imaging and laboratory findings who underwent ERCP and LC during a single anesthetic were identified from the electronic medical record (2016–2018). These were then randomly matched 3:1 to patients preoperatively diagnosed with choledocholithiasis based on imaging and laboratory findings who underwent these procedures during separate anesthetics. An expanded timeframe was used for matching of controls to ensure parity (2013–2018). All cases were performed laparoscopically. Demographic and clinical outcomes data were collected for each patient, including age, ethnicity, insurance and transfer status, preoperative imaging and laboratory findings, length of anesthesia, cost of stay, postoperative complications, and follow-up. Cost of stay was determined from billing data, which reflects all hospital charges during the choledocholithiasis admission. Standardized forms were implemented for data collection. Requirement for consent was waived by the IRB given the retrospective nature of this study.

Statistical analysis

Patients who underwent separate ERCP and LC and those who had both procedures during the same anesthetic were compared to identify differences in demographic and clinical features between groups. Fisher's exact test was used to differentiate categorical data, and Mann–Whitney U test was employed to compare means. All analyses were completed in SPSS^® v25 for MacOS (IBM Corp. Released 2017. IBM SPSS Statistics for Macintosh, Version 25.0. Armonk, NY: IBM Corp.).

Results

There were 14 patients who underwent concurrent LC and ERCP during a single anesthetic. These were randomly matched 3:1 to 42 patients who underwent LC and ERCP as separate procedures. Table 1 exhibits baseline demographic information between concurrent and separate cases. There were similar proportions of female patients, mean age, ethnicity, race, transfer status, and insurance coverage between the two groups (P > .05 for each).

Table 1.

Baseline Patient Characteristics

	Concurrent (n = 14)	Separate (n = 42)	P
Female, n (%)	6 (42.9)	10 (23.8)	.190
Age, mean years ± SD (range)	14.2 ± 3.9 (3–18)	14.2 ± 2.0 (9–17)	.250
Ethnicity, n (%)	8 (57.1)	24 (57.1)	1.000
Race, n (%)
White	6 (42.9)	27 (64.3)	.347
African American	5 (35.7)	9 (21.4)
Asian	0 (0.0)	0 (0.0)
Native Hawaiian or Pacific Islander	0 (0.0)	0 (0.0)
Other	3 (21.4)	6 (14.3)
Transfer patient, n (%)	5 (35.7)	23 (54.8)	.355
Insurance status, n (%)
Commercial	3 (21.4)	13 (31.0)	.774
Public	10 (31.0)	27 (64.3)
Self-pay	1 (28.6)	2 (4.8)

Demographics are compared between pediatric patients with choledocholithiasis who underwent concurrent laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography under one anesthetic versus those who underwent both procedures under separate anesthetics.

SD, standard deviation.

In Table 2, we compare preoperative factors between concurrent anesthetic and separate anesthetic cases. All patients had a preoperative ultrasound, and small proportions of both cohorts had a preoperative computed tomography (P = 1.000). Although no patients in the concurrent anesthetic group underwent a magnetic resonance cholangiopancreatography (MRCP), 14.3% of separate anesthetic patients had MRCP, which was not a statistically significant difference (P = .391). The mean common bile duct diameter noted on ultrasound report was not significantly different between groups (P = .126), nor were preoperative levels of total bilirubin, direct bilirubin, or white blood cells (P > .05 for each).

Table 2.

Preoperative Characteristics

	Concurrent (n = 14)	Separate (n = 42)	P
Imaging, n (%)
US	14 (100.0)	42 (100.0)	1.000
CT	1 (7.1)	4 (9.5)	1.000
MRCP	0 (0.0)	6 (14.3)	.319
Common bile duct diameter, mm ± SD	7.46 ± 3.2	9.0 ± 3.0	.151
Total bilirubin, mean mg/dL ± SD	5.0 ± 5.4	5.0 ± 9.0	.416
Direct bilirubin, mean mg/dL ± SD	2.8 ± 3.9	3.4 ± 6.5	.984
White blood cell count, mean cells × 10⁹/L ± SD	9.7 ± 3.4	8.2 ± 2.6	.150

Preoperative factors are compared between pediatric patients with choledocholithiasis who underwent concurrent laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography under one anesthetic versus those who underwent both procedures under separate anesthetics.

CT, computed tomography; MRCP, magnetic resonance cholangiopancreatography; SD, standard deviation; US, ultrasound.

Table 3 compares the operative and postoperative outcomes of concurrent and separate anesthetic patients. Total anesthesia time was 118 minutes for concurrent anesthetic patients, and 120 minutes for separate anesthetic cases, which was not significantly different (P = .747). However, the patients who received ERCP and LC during separate anesthetics possessed a mean latency of 1.5 days between their procedures, as opposed to no latency for the concurrent group (P = .000). Length of stay did not differ between groups, at 3.8 days for concurrent and 3.9 days for separate anesthetics (P = .912). However, cost of stay was significantly higher in the patients who received procedures during separate anesthetics, with an average cost of stay at $61,008 compared with $45,597 in concurrent anesthetic patients (P = .006). The rate of complications was low in both groups. There was 1 case of bleeding in the concurrent anesthetic group, 2 in the separate group (P = 1.000), and no surgical site in infections in either cohort (P = 1.000). Two patients in the separate anesthesia group had other complications, including 1 case of cholangitis 5 months postoperatively related to retained biliary stent, and 1 who presented with pancreatic pseudocyst a month postoperatively. No further complications were noted in the concurrent anesthetic group (P = 1.000). Median follow-up time was similar between groups, at 4 weeks in concurrent anesthesia patients and 3 weeks in separate anesthesia patients (P = .605). Although there were no postoperative ED visits or readmissions in the concurrent group, there were 2 postoperative ED visits in the separate group (P = 1.000) and 3 readmissions in the separate group (P = .565).

Table 3.

Clinical Outcomes and Costs

	Concurrent (n = 14)	Separate (n = 42)	P
Total anesthesia length, mean minutes ± SD	117.9 ± 40.0	119.6 ± 52.2	.813
Latency between procedures, mean days ± SD	0.0 ± 0.0	1.5 ± 0.7	.000
Length of stay, mean days ± SD	3.8 ± 2.3	3.9 ± 1.4	.127
Cost of stay, mean dollars ± SD	45,597 ± 11,513	61,008 ± 17,960	.002
Complications, n (%)
Bleeding	1 (7.1)	2 (4.8)	1.000
Surgical site infection	0 (0.0)	0 (0.0)	1.000
Other	0 (0.0)	2 (4.8)	1.000
Follow-up time, median weeks (range)	4 (0–15)	3 (0–12)	.702
Postoperative ED visits, n (%)	0 (0.0)	2 (4.8)	1.000
Readmissions, n (%)	0 (0.0)	3 (7.1)	.565

Operative data and postoperative outcomes are compared between pediatric patients with choledocholithiasis who underwent concurrent laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography under one anesthetic versus those who underwent both procedures under separate anesthetics.

ED, emergency department; SD, standard deviation.

Discussion

In this study, we examined an innovative strategy developed between gastroenterology and pediatric surgery to perform LC and ERCP during the same anesthetic. We compared those who underwent concurrent LC and ERCP with those who underwent separate procedures. We found that there is no difference in total anesthesia time, although concurrent patients received only one anesthesia induction. The concurrent procedure cohort had a significantly lower cost of stay with no difference in complication or readmission rate and similar follow-up times. There were minimal complications found in both groups with no cases of post-ERCP pancreatitis or retained stone in either group. The separate procedure group had two ED visits both for abdominal pain related to constipation. There was 1 case of postsphincterotomy bleeding in the concurrent group that required repeat ERCP. The 2 cases of bleeding in the separate group were completely unrelated to the procedure: 1 was found to be caused by postpartum hemorrhage and the other related to sickle cell anemia.

Historically, pediatric LC was frequently performed for hemolytic disease. With rates of obesity and cholesterol stone formation increasing, the most common indication for LC in children has shifted.^1,13 The increased risk of obstructive biliary disease in children necessitates ductal intervention in this population.^5–7 The management of complicated gallstone disease in adults has shifted from open to endoscopic approach with the rise of advanced interventional gastroenterology.¹⁴ With ERCP taking the place of open common duct explorations, the risk of bile duct injury in open common duct explorations has increased in the adult population.¹⁵ Pediatric patients are at an increased risk for bile duct injury during LC, and unlike what is seen with adults, intraoperative cholangiogram does not decrease that risk.¹⁶ Laparoscopic CBDE is a strategic cost-effective option to manage pediatric choledocholithiasis, but may not be widely available.¹⁷ For many institutions, ERCP is attractive as the treatment of choice for obstructing common bile duct stones in children.

Although ERCP and LC may be advantageous to treat obstructing biliary disease in children, currently most children with choledocholithiasis are subjected to two anesthetics: 1 for their ERCP and 1 for their LC. We know that early exposure to anesthesia in animal models increases neuronal cell death and apoptotic events.^18,19 Likewise, although exposure to one anesthetic in childhood was not associated with any increased risk of learning disabilities, exposure to two or more anesthesia events did significantly increase this risk.^8,9 Although these data are most relevant to infants and toddlers, our cohort mean age was 14 years, at which point the human brain is still developing. Therefore, reducing anesthetic exposure, along with the risks associated with multiple anesthesia inductions, remains important for older children and adolescents.

Importantly, this study uncovered a significant difference in the hospital between the two management strategies, with LC and ERCP during one anesthetic outperforming separate anesthetics with regard to cost. The mean difference between the two approaches was $15,411 USD, which cannot be accounted for by the higher rate of MRCP use in the separate procedure group. In the current environment of value-based care, this significant cost difference is an important aspect of our study.

This study was limited by its small sample size and retrospective nature. Although the study was powered to detect significant differences between costs of stay, it is possible that no other significant differences were detected between groups due to small sample size. For example, there was no difference in total anesthesia length between groups (although the concurrent group did benefit from receipt of only one anesthesia induction). In addition, our practices are changing and rates of laparoscopic CBDE are increasing at our institution. This will also allow concentration of multiple procedures into a single anesthetic as an alternative to concurrent LC and ERCP and presents an opportunity for future study. We hope to participate in a multi-institutional prospective study to strengthen our findings and reduce bias from the sample size and retrospective single-institution nature of this study.

We conclude that concurrent LC and ERCP in the pediatric population is a safe and cost-effective way to treat choledocholithiasis without increased complications. This is an advantageous strategy to decrease pediatric exposure to anesthesia induction during the treatment of choledocholithiasis.

Footnotes

Acknowledgments

We acknowledge the assistance of Lorrie S. Burkhalter, MPH, and Gentry Wools, RN, BSN, in obtaining institutional approval and locating control cases.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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