Surg Endosc DOI 10.1007/s00464-014-3872-4
and Other Interventional Techniques
Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children C. O. Muller • M. B. Boimond • A. Rega • D. Michelet • A. El Ghoneimi • A. Bonnard
Received: 7 April 2014 / Accepted: 2 September 2014 Ó Springer Science+Business Media New York 2014
Abstract Background The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children. Methods All children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up. Results 551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5 %) presented with CBD stones with a mean age at symptom onset of 10.4 years (min–max: 4 months–18 years). A majority of the patients presented with hemolytic disease (61 %). In 55 % of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72 % of success rate. In 9 cases (25 %) of C. O. Muller (&) M. B. Boimond A. El Ghoneimi A. Bonnard Pediatric Surgery Department, Hoˆpital Robert Debre´, Paris APHP, 48 bvd Serrurier, 75019 Paris, France e-mail: [email protected]; [email protected] A. Bonnard e-mail: [email protected] A. Rega Radiologic Department, Hoˆpital Robert Debre´, Paris APHP, Paris, France D. Michelet Anesthetic Department, Hoˆpital Robert Debre´, Paris APHP, Paris, France
failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2 years (min–max: 1 month–5 years). All patients were stone free at last clinical and radiological evaluation. Conclusion A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72 % of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children. Keywords Children
Common bile duct stones Laparoscopy
Cholelithiasis is a rare condition in children (1 %), mainly due to hemolytic disorders and distal ileum pathology in infancy and dyslipidemia in adolescents. Common bile duct (CBD) stones occur in 10–20 % of cholelithiasis, depending on the underlying pathology and the age of the child [1]. A sequential approach with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is an effective and standardized treatment of CBD stones in adults. In children, this treatment remains controversial. Although experience with diagnostic and therapeutic ERCP with ES in children has been growing in the past few
123
Surg Endosc Table 1 Patients’ characteristics
Number of patients
36
Mean age at surgery (years, min–max)
11 (0.25–18)
Etiology Sickle cell anemia Minkowski-Chauffard disease
14 (25 %) 5 (14 %)
Mevalonate kinase deficit
1 (2.7 %)
G6PD deficit
1 (2.7 %)
Thalassemia
1 (2.7 %)
Hemorrhagic rectocolitis
1 (2.7 %)
Nephrotic syndrome
1 (2.7 %)
Idiopathic
12 (33 %)
Clinical symptoms Fever
3 (8.3 %)
Jaundice
23 (64 %)
Abdominal pain
32 (88 %)
Blood tests
GGT gammaglutamyl transfe´rase, ALP alkaline phosphatase, CBD common bile duct
AST/ALT
N \ 45 IU/l
3.2N/5.4N
GGT
N \ 35 IU/l
227.5
ALP Conjugated bilirubin
N \ 400 IU/l N \ 5 umol/l
161 81
Lipase
N \ 40 IU/l
395
US scan CBD dilatation, mean diameter (min–max)
74 %, 7.5 mm (5–14.5)
CBD stones diagnosis
43 %
years [2–4], there are few data concerning safety and technical outcomes in comparison with ERCP in adults [5]. Moreover, ERCP realization requires almost systematically general anesthesia (GA) in children [4]. At last, long-term consequences of ERCP with ES on the papilla and cancer risk in children have not been evaluated yet. For these reasons, we chose a one-stage total laparoscopic treatment of CBD stones in children and wanted to report our experience in terms of safety and efficacy of this technique.
Patients and methods We retrospectively reviewed the records of all children managed for cholelithiasis in Robert Debre´ Hospital from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications such as pancreatitis, bleeding, and retained stones with associated management, and stone-free status or not, at last follow-up. The laparoscopic technique of cholecystectomy associated with a per-operative cholangiography has been
123
Mean values
previously described by us and others, using either physiological serum saline flush, Fogarty catheter or Dormia basket to clear the CBD [6, 7]. In summary, patient is placed in French position, operator between the legs, in reverse Trendelenburg during the cholangiogram. A 3 operative port technique is used as described previously [7] Cholangiogram is performed using a transcystic approach. We use a 14-gauge needle with a catheter introduced under direct vision through the abdominal wall near the cystic duct. Then, a 3F or 5F ureteral catheter is introduced through the catheter in the cystic duct, which is not totally cut. Cholangiogram is accomplished using fluoroscopy for a dynamic visualization of the biliary tree. If obstruction is confirmed, all these children undergo a flush of the CBD with normal saline serum. In addition, if necessary, an extraction of the stone through the cystic duct is performed, using a Fogarty catheter or a 3F Dormia basket catheter introduced through the catheter. The stone is either pushed into the duodenum. For some patients, we found easier to use a per-operative cholangiogram Kit (Percutaneous cholangiogram Kit AEROSTATÒ Applied). Management of CBD stones in our institution included pre-operative US scan, performed or reviewed by a senior radiologist, repeated at 1 month after surgery to assess stone-free status.
Surg Endosc Fig. 1 Management of common bile duct (CBD) stones
Patients with per operative cholangiography n = 36
Normal cholangiogram
Obstructive cholangiogram
n = 14
n = 22
Flush with serum saline
Conversion to open surgery n=1
n = 21
Normal cholangiogram
Failure : Dormia/Fogarty n =12
n=9
Success n = 6
Failure with CBD stones on control US scan n=3
Failure : Lithiasis n=5
Post operative ERCP + SE : Stone free at last follow up
Normal cholangiogram n=7
Success n = 6
n=2
Redo surgery at day 1 for hemorrage, cholangiography and biliary external drainage n =1
Failure with CBD stones on control US scan n=1
Follow up with US scan at 1 month : Stone free n=2
Results From 1996 to 2013, 551 patients were treated for cholelithiasis in Robert Debre´ Hospital, of which 36 presented with choledocholithiasis. Patients’ characteristics with CBD stones are displayed on Table 1. Among the 36 patients with CBD stones, complete data were available for 33 patients. Eleven patients had pancreatitis diagnosed on CT scan, and 3 patients presented with cholangitis. Mean delay between symptoms onset and surgery was 10 days
(2 days–1 month). Mean weight for patients with no predisposing disease was ?3.5DS (min–max: 2–4). All children (100 %) were treated by laparoscopic cholecystectomy with intraoperative exploration of the CBD by cholangiography. Results of CBD management are displayed on Fig. 1. 38 % of the patients had a normal cholangiogram in spite of diagnosis of CBD stones on US scan in 16 % of these cases. 62 % of the patients had an obstructive cholangiogram, with CBD diagnosed on US scan in 66 % of these cases.
123
Surg Endosc
In 55 % of the cases, cholangiography alone or simple normal saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter lead to 72 % of success rate. Four patients with a final normal cholangiogram presented with CBD dilatation and visible stones on control US scan performed because of cholestatic symptoms. All were scheduled for ERCP and SE at day 7 post-operatively on average. One patient required 2 ERCP to clear the CBD. All patients were stone free at last follow-up. In 5 cases (14 %), final cholangiogram was still obstructive with a failure of the procedure. Two patients underwent ERCP with SE at day 9 and 14, respectively and were stone free at last follow-up. One patient was reoperated on by laparotomy at day 1 for hemorrhage, underwent a second per operative cholangiography with external biliary drainage, removed 6 weeks there after with a normal cholangiogram. This patient was asymptomatic and stone free 5 years later, but presented with a persisted CBD dilatation between 5 and 10 mm. The last 2 patients were simply followed by US scan and were stone free at last clinical examination. Complication rate of cholecystectomy associated with cholangiography was 5 %: 2 patients were re-operated on at day one for hemorrhage. Complication rate of ERCP with SE was null. Mortality was null. Mean operative time was of 142 min (min–max: 30–220), the laparoscopic procedure having been performed either by junior and senior surgeons of the team. Mean hospital stay for the whole series was of 4.4 days (min–max: 1–23). Mean follow-up was of 2 years (min– max: 1 month–5 years). Two patients were lost to followup. All other patients were stone free at the last clinical and radiological evaluation.
Discussion A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72 % of the cases, using only a normal saline flush in most of the cases without the need of an additional catheter or endoscopy of the CBD. Management of CBD stones in children is not standardized, and still varies according to the surgical team habits. Firstly, the laparoscopic cholecystectomy is not mandatory for all authors in small children with no predisposing disease: percutaneous clearance of the CBD is a possibility in expert radiologic pediatric centers with satisfying results [1]. Our point of view is that most of our patients without hemolytic disease were adolescents with high body mass index and should be treated like adults with hypercholesterolemia, with systematic laparoscopic cholecystectomy.
123
Once laparoscopic cholecystectomy has been decided, some authors chose not to investigate per-operatively the CBD if a pre-operative magnetic resonance cholangiopancreatography (MRCP) did not show any CBD stones [8]. Only one patient in our series benefited from a MRCP due to lack of radiologic experience in this field in our center. MRCP requires radiological skills for analysis and presents with several disadvantages: the poor definition of the intrahepatic biliary tree, the inherent poor spatial resolution for small stones, and for tiny pancreatic and bile ducts in children, cost and availability [3, 9]. However, other studies about MRCP using secretin are more promising with a sensitivity and specificity approaching 98 up to 100 %, respectively, in patients with common bile duct obstruction [2]. In our series, US scan was quite a reliable pre-operative evaluation of CBD stones with 66 % of US diagnosis in patients with an obstructive cholangiogram, as reported in other studies [10, 11]. However, this diagnosis rate is not sufficient for us and must be upgraded by systematic peroperative cholangiography. The high rate of normal cholangiogram in our series (38 %) only illustrates the fact that small stones often pass through the Oddi sphincter spontaneously. Indeed, some authors advocate a simple US and clinical follow-up of patients with obstructive cholangiogram [12] but this favorable evolution is hardly predictable and exposes the child to recurrent cholangitis or pancreatitis. Once the surgical team has chosen to manage CBD stones with systematic laparoscopic cholecystectomy and systematic clearance of the CBD, there still remains several techniques to perform it. Our point of view is to explore the CBD and attempt to clear it with per-operative cholangiogram during the same anesthesia. This technique presents the advantage of being both diagnostic and therapeutic through the serum saline flush of the CBD and the use of the Fogarty catheter and Dormia basket in case of failure. As a matter of fact, we only use the endoscopic retrograde cholangiopancreatography (ERCP) as the last option to obtain clearance of the CBD, a few days after laparoscopic cholecystectomy, requiring a second general anesthesia. In fact, ERCP associated with endoscopic sphincterotomy (ES) can be performed before or after laparoscopic cholecystectomy as in adults. Secondary migration of stones can occur if ERCP is realized before removal of the gallbladder. As a second step, ERCP is reported to have similar rates of both success and complications in children as in adult literature [2, 4, 5]. The development of smallcaliber fiberoptic duodenoscopes has increased the use of ERCP in the pediatric population in the last few years. However, maintaining skills requires doing more ERCP than a pediatric gastroenterologist may perform even in a university center such as ours. Indeed, a large, multicenter
Surg Endosc
prospective cohort study of complications after ERCP sphincterotomy found that the incidence of complications is primarily determined by the volume of procedures performed by endoscopists rather than patient age or medical condition [13]. Moreover, the major differences between ERCP in child and adult patients is related to the type of anesthesia administered and the type of duodenoscope used. This fact made Rocca et al. to advocate the rendezvous technique with intraoperative treatment of CBD stones while laparoscopic cholecystectomy which avoids two sessions of general anesthesia and reduces the risk of ERCP-related pancreatitis, thanks to selective bile duct cannulation [3]. However, documented experience with ERCP for pediatric patients remains limited for several reasons. Notable issues include the relative rarity of pancreaticobiliary diseases requiring surgery among children, the fairly recent advent of the pediatric duodenoscope, and the lack of safety information and accepted indications for ERCP in children. There is no data available about risk cancer after ERCP associated with SE in the pediatric population. In a series of 27,708 adult patients, Stromberg et al. showed that the risk of malignancy in the bile ducts, liver, or pancreas was elevated after ERCP in benign disease like CBD stones. However, ES did not seem to affect this risk [14]. Besides, possible complications of ES are hemorrhage, pancreatitis, and perforation and led Osanai et al. to advocate endoscopic ballon dilation of the Oddi sphincter in children [15]. The last technique that could be used and be developed in children but has not been described yet in this population is the laparoscopic common bile duct endoscopy (LCBDE), as reported by Ricciardi et al. in adults. Innovations in small-diameter fiberoptic scopes and increasing expertise in laparoscopy have allowed surgeons to expand minimally invasive techniques, especially in the area of hepatobiliary surgery. The LCBDE procedure requires advanced laparoscopic skills, in addition to a dedicated team in the operating room. An institutional commitment in the form of purchasing and maintaining equipment also is needed. Thus, because of the high start-up costs and surgical expertise involved with LCBDE, the widespread application of LCBDE has been somewhat limited. The authors think that ERCP with ES has been overutilized since the advent of LC. The addition of ERCP with ES as a second procedure increases the overall cost, length of stay, and complication rate, compared to LCBDE [16].
Conclusion In our opinion, the optimum management of CBD stones requires laparoscopic cholecystectomy and clearance of the
CBD during the same anesthesia in children, with preservation of the Oddi sphincter. Our 72 % success rate with per-operative cholangiography is a satisfying result, but could be upgraded by the development of LCBDE in cooperation with our pediatric gastroenterologists.
Disclosures Muller C. O, Boimond M. B, Rega A, Michelet D, El Ghoneimi A, and Bonnard A have no conflicts of interest or financial ties to disclose.
References 1. Debray D, Franchi-Abella S, Irtan S, Girard M (2012) Cholelithiasis in infants, children and adolescents. Presse Med 41: 466–473 2. Paris C, Bejjani J, Beaunoyer M, Ouimet A (2010) Endoscopic retrograde cholangiopancreatography is useful and safe in children. J Pediatr Surg 45:938–942 3. Rocca R, Castellino F, Daperno M, Masoero G, Sostegni R, Ercole E, Lavagna A, Barbera C, Canavese F, Pera A (2005) Therapeutic ERCP in paediatric patients. Dig Liver Dis 37: 357–362 4. Varadarajulu S, Wilcox CM, Hawes RH, Cotton PB (2004) Technical outcomes and complications of ERCP in children. Gastrointest Endosc 60:367–371 5. Otto AK, Neal MD, Slivka AN, Kane TD (2011) An appraisal of endoscopic retrograde cholangiopancreatography (ERCP) for pancreaticobiliary disease in children: our institutional experience in 231 cases. Surg Endosc 25:2536–2540 6. Shah RS, Blakely ML, Lobe TE (2001) The role of laparoscopy in the management of common bile duct obstruction in children. Surg Endosc 15:1353–1355 7. Bonnard A, Seguier-Lipszyc E, Liguory C, Benkerrou M, Garel C, Malbezin S, Aigrain Y, de Lagausie P (2005) Laparoscopic approach as primary treatment of common bile duct stones in children. J Pediatr Surg 40:1459–1463 8. Chan S, Currie J, Malik AI, Mahomed AA (2008) Paediatric cholecystectomy: Shifting goalposts in the laparoscopic era. Surg Endosc 22:1392–1395 9. Metreweli C, So NMC, Chu WCW, Lam WWM (2004) Magnetic resonance cholangiography in children. Br J Radiol 77:1059– 1064 10. Menon S, Patel B, Saekang E, Thomas G, Soundappan S, Shun A (2011) Laparoscopic exploration of the common bile duct to relieve choledocholithiasis in children. Pediatr Surg Int 27:537– 540 11. Tannuri ACA, Leal AJG, Velhote MCP, Gonlc¸alves MEP, Tannuri U (2012) Management of gallstone disease in children: a new protocol based on the experience of a single center. J Pediatr Surg 47:2033–2038 12. Vrochides DV, Sorrells DL Jr, Kurkchubasche AG, Wesselhoeft CW Jr, Tracy TF Jr, Luks FI (2005) Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children? Arch Surg 140: 359–361 13. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM (1996) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335:909–918 14. Stro¨mberg C, Luo J, Enochsson L, Arnelo U, Nilsson M (2008) Endoscopic sphincterotomy and risk of malignancy in the bile
123
Surg Endosc ducts, liver, and pancreas. Clin Gastroenterol Hepatol 6:1049–1053 15. Osanai M, Maguchi H, Takahashi K, Katanuma A, Yane K, Kaneko M, Hashigo S, Katoh S, Harada R, Katoh R, Tanno S (2011) Safety and long-term outcomes of endoscopic papillary balloon dilation in children with bile duct stones. Gastrointest Endosc 73:619–623
123
16. Riciardi R, Islam S, Canete JJ, Arcand PL, Stoker ME (2003) Effectiveness and long-term results of laparoscopic common bile duct exploration. Surg Endosc 17:19–22
and Other Interventional Techniques
Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children C. O. Muller • M. B. Boimond • A. Rega • D. Michelet • A. El Ghoneimi • A. Bonnard
Received: 7 April 2014 / Accepted: 2 September 2014 Ó Springer Science+Business Media New York 2014
Abstract Background The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children. Methods All children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up. Results 551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5 %) presented with CBD stones with a mean age at symptom onset of 10.4 years (min–max: 4 months–18 years). A majority of the patients presented with hemolytic disease (61 %). In 55 % of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72 % of success rate. In 9 cases (25 %) of C. O. Muller (&) M. B. Boimond A. El Ghoneimi A. Bonnard Pediatric Surgery Department, Hoˆpital Robert Debre´, Paris APHP, 48 bvd Serrurier, 75019 Paris, France e-mail: [email protected]; [email protected] A. Bonnard e-mail: [email protected] A. Rega Radiologic Department, Hoˆpital Robert Debre´, Paris APHP, Paris, France D. Michelet Anesthetic Department, Hoˆpital Robert Debre´, Paris APHP, Paris, France
failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2 years (min–max: 1 month–5 years). All patients were stone free at last clinical and radiological evaluation. Conclusion A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72 % of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children. Keywords Children
Common bile duct stones Laparoscopy
Cholelithiasis is a rare condition in children (1 %), mainly due to hemolytic disorders and distal ileum pathology in infancy and dyslipidemia in adolescents. Common bile duct (CBD) stones occur in 10–20 % of cholelithiasis, depending on the underlying pathology and the age of the child [1]. A sequential approach with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is an effective and standardized treatment of CBD stones in adults. In children, this treatment remains controversial. Although experience with diagnostic and therapeutic ERCP with ES in children has been growing in the past few
123
Surg Endosc Table 1 Patients’ characteristics
Number of patients
36
Mean age at surgery (years, min–max)
11 (0.25–18)
Etiology Sickle cell anemia Minkowski-Chauffard disease
14 (25 %) 5 (14 %)
Mevalonate kinase deficit
1 (2.7 %)
G6PD deficit
1 (2.7 %)
Thalassemia
1 (2.7 %)
Hemorrhagic rectocolitis
1 (2.7 %)
Nephrotic syndrome
1 (2.7 %)
Idiopathic
12 (33 %)
Clinical symptoms Fever
3 (8.3 %)
Jaundice
23 (64 %)
Abdominal pain
32 (88 %)
Blood tests
GGT gammaglutamyl transfe´rase, ALP alkaline phosphatase, CBD common bile duct
AST/ALT
N \ 45 IU/l
3.2N/5.4N
GGT
N \ 35 IU/l
227.5
ALP Conjugated bilirubin
N \ 400 IU/l N \ 5 umol/l
161 81
Lipase
N \ 40 IU/l
395
US scan CBD dilatation, mean diameter (min–max)
74 %, 7.5 mm (5–14.5)
CBD stones diagnosis
43 %
years [2–4], there are few data concerning safety and technical outcomes in comparison with ERCP in adults [5]. Moreover, ERCP realization requires almost systematically general anesthesia (GA) in children [4]. At last, long-term consequences of ERCP with ES on the papilla and cancer risk in children have not been evaluated yet. For these reasons, we chose a one-stage total laparoscopic treatment of CBD stones in children and wanted to report our experience in terms of safety and efficacy of this technique.
Patients and methods We retrospectively reviewed the records of all children managed for cholelithiasis in Robert Debre´ Hospital from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications such as pancreatitis, bleeding, and retained stones with associated management, and stone-free status or not, at last follow-up. The laparoscopic technique of cholecystectomy associated with a per-operative cholangiography has been
123
Mean values
previously described by us and others, using either physiological serum saline flush, Fogarty catheter or Dormia basket to clear the CBD [6, 7]. In summary, patient is placed in French position, operator between the legs, in reverse Trendelenburg during the cholangiogram. A 3 operative port technique is used as described previously [7] Cholangiogram is performed using a transcystic approach. We use a 14-gauge needle with a catheter introduced under direct vision through the abdominal wall near the cystic duct. Then, a 3F or 5F ureteral catheter is introduced through the catheter in the cystic duct, which is not totally cut. Cholangiogram is accomplished using fluoroscopy for a dynamic visualization of the biliary tree. If obstruction is confirmed, all these children undergo a flush of the CBD with normal saline serum. In addition, if necessary, an extraction of the stone through the cystic duct is performed, using a Fogarty catheter or a 3F Dormia basket catheter introduced through the catheter. The stone is either pushed into the duodenum. For some patients, we found easier to use a per-operative cholangiogram Kit (Percutaneous cholangiogram Kit AEROSTATÒ Applied). Management of CBD stones in our institution included pre-operative US scan, performed or reviewed by a senior radiologist, repeated at 1 month after surgery to assess stone-free status.
Surg Endosc Fig. 1 Management of common bile duct (CBD) stones
Patients with per operative cholangiography n = 36
Normal cholangiogram
Obstructive cholangiogram
n = 14
n = 22
Flush with serum saline
Conversion to open surgery n=1
n = 21
Normal cholangiogram
Failure : Dormia/Fogarty n =12
n=9
Success n = 6
Failure with CBD stones on control US scan n=3
Failure : Lithiasis n=5
Post operative ERCP + SE : Stone free at last follow up
Normal cholangiogram n=7
Success n = 6
n=2
Redo surgery at day 1 for hemorrage, cholangiography and biliary external drainage n =1
Failure with CBD stones on control US scan n=1
Follow up with US scan at 1 month : Stone free n=2
Results From 1996 to 2013, 551 patients were treated for cholelithiasis in Robert Debre´ Hospital, of which 36 presented with choledocholithiasis. Patients’ characteristics with CBD stones are displayed on Table 1. Among the 36 patients with CBD stones, complete data were available for 33 patients. Eleven patients had pancreatitis diagnosed on CT scan, and 3 patients presented with cholangitis. Mean delay between symptoms onset and surgery was 10 days
(2 days–1 month). Mean weight for patients with no predisposing disease was ?3.5DS (min–max: 2–4). All children (100 %) were treated by laparoscopic cholecystectomy with intraoperative exploration of the CBD by cholangiography. Results of CBD management are displayed on Fig. 1. 38 % of the patients had a normal cholangiogram in spite of diagnosis of CBD stones on US scan in 16 % of these cases. 62 % of the patients had an obstructive cholangiogram, with CBD diagnosed on US scan in 66 % of these cases.
123
Surg Endosc
In 55 % of the cases, cholangiography alone or simple normal saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter lead to 72 % of success rate. Four patients with a final normal cholangiogram presented with CBD dilatation and visible stones on control US scan performed because of cholestatic symptoms. All were scheduled for ERCP and SE at day 7 post-operatively on average. One patient required 2 ERCP to clear the CBD. All patients were stone free at last follow-up. In 5 cases (14 %), final cholangiogram was still obstructive with a failure of the procedure. Two patients underwent ERCP with SE at day 9 and 14, respectively and were stone free at last follow-up. One patient was reoperated on by laparotomy at day 1 for hemorrhage, underwent a second per operative cholangiography with external biliary drainage, removed 6 weeks there after with a normal cholangiogram. This patient was asymptomatic and stone free 5 years later, but presented with a persisted CBD dilatation between 5 and 10 mm. The last 2 patients were simply followed by US scan and were stone free at last clinical examination. Complication rate of cholecystectomy associated with cholangiography was 5 %: 2 patients were re-operated on at day one for hemorrhage. Complication rate of ERCP with SE was null. Mortality was null. Mean operative time was of 142 min (min–max: 30–220), the laparoscopic procedure having been performed either by junior and senior surgeons of the team. Mean hospital stay for the whole series was of 4.4 days (min–max: 1–23). Mean follow-up was of 2 years (min– max: 1 month–5 years). Two patients were lost to followup. All other patients were stone free at the last clinical and radiological evaluation.
Discussion A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72 % of the cases, using only a normal saline flush in most of the cases without the need of an additional catheter or endoscopy of the CBD. Management of CBD stones in children is not standardized, and still varies according to the surgical team habits. Firstly, the laparoscopic cholecystectomy is not mandatory for all authors in small children with no predisposing disease: percutaneous clearance of the CBD is a possibility in expert radiologic pediatric centers with satisfying results [1]. Our point of view is that most of our patients without hemolytic disease were adolescents with high body mass index and should be treated like adults with hypercholesterolemia, with systematic laparoscopic cholecystectomy.
123
Once laparoscopic cholecystectomy has been decided, some authors chose not to investigate per-operatively the CBD if a pre-operative magnetic resonance cholangiopancreatography (MRCP) did not show any CBD stones [8]. Only one patient in our series benefited from a MRCP due to lack of radiologic experience in this field in our center. MRCP requires radiological skills for analysis and presents with several disadvantages: the poor definition of the intrahepatic biliary tree, the inherent poor spatial resolution for small stones, and for tiny pancreatic and bile ducts in children, cost and availability [3, 9]. However, other studies about MRCP using secretin are more promising with a sensitivity and specificity approaching 98 up to 100 %, respectively, in patients with common bile duct obstruction [2]. In our series, US scan was quite a reliable pre-operative evaluation of CBD stones with 66 % of US diagnosis in patients with an obstructive cholangiogram, as reported in other studies [10, 11]. However, this diagnosis rate is not sufficient for us and must be upgraded by systematic peroperative cholangiography. The high rate of normal cholangiogram in our series (38 %) only illustrates the fact that small stones often pass through the Oddi sphincter spontaneously. Indeed, some authors advocate a simple US and clinical follow-up of patients with obstructive cholangiogram [12] but this favorable evolution is hardly predictable and exposes the child to recurrent cholangitis or pancreatitis. Once the surgical team has chosen to manage CBD stones with systematic laparoscopic cholecystectomy and systematic clearance of the CBD, there still remains several techniques to perform it. Our point of view is to explore the CBD and attempt to clear it with per-operative cholangiogram during the same anesthesia. This technique presents the advantage of being both diagnostic and therapeutic through the serum saline flush of the CBD and the use of the Fogarty catheter and Dormia basket in case of failure. As a matter of fact, we only use the endoscopic retrograde cholangiopancreatography (ERCP) as the last option to obtain clearance of the CBD, a few days after laparoscopic cholecystectomy, requiring a second general anesthesia. In fact, ERCP associated with endoscopic sphincterotomy (ES) can be performed before or after laparoscopic cholecystectomy as in adults. Secondary migration of stones can occur if ERCP is realized before removal of the gallbladder. As a second step, ERCP is reported to have similar rates of both success and complications in children as in adult literature [2, 4, 5]. The development of smallcaliber fiberoptic duodenoscopes has increased the use of ERCP in the pediatric population in the last few years. However, maintaining skills requires doing more ERCP than a pediatric gastroenterologist may perform even in a university center such as ours. Indeed, a large, multicenter
Surg Endosc
prospective cohort study of complications after ERCP sphincterotomy found that the incidence of complications is primarily determined by the volume of procedures performed by endoscopists rather than patient age or medical condition [13]. Moreover, the major differences between ERCP in child and adult patients is related to the type of anesthesia administered and the type of duodenoscope used. This fact made Rocca et al. to advocate the rendezvous technique with intraoperative treatment of CBD stones while laparoscopic cholecystectomy which avoids two sessions of general anesthesia and reduces the risk of ERCP-related pancreatitis, thanks to selective bile duct cannulation [3]. However, documented experience with ERCP for pediatric patients remains limited for several reasons. Notable issues include the relative rarity of pancreaticobiliary diseases requiring surgery among children, the fairly recent advent of the pediatric duodenoscope, and the lack of safety information and accepted indications for ERCP in children. There is no data available about risk cancer after ERCP associated with SE in the pediatric population. In a series of 27,708 adult patients, Stromberg et al. showed that the risk of malignancy in the bile ducts, liver, or pancreas was elevated after ERCP in benign disease like CBD stones. However, ES did not seem to affect this risk [14]. Besides, possible complications of ES are hemorrhage, pancreatitis, and perforation and led Osanai et al. to advocate endoscopic ballon dilation of the Oddi sphincter in children [15]. The last technique that could be used and be developed in children but has not been described yet in this population is the laparoscopic common bile duct endoscopy (LCBDE), as reported by Ricciardi et al. in adults. Innovations in small-diameter fiberoptic scopes and increasing expertise in laparoscopy have allowed surgeons to expand minimally invasive techniques, especially in the area of hepatobiliary surgery. The LCBDE procedure requires advanced laparoscopic skills, in addition to a dedicated team in the operating room. An institutional commitment in the form of purchasing and maintaining equipment also is needed. Thus, because of the high start-up costs and surgical expertise involved with LCBDE, the widespread application of LCBDE has been somewhat limited. The authors think that ERCP with ES has been overutilized since the advent of LC. The addition of ERCP with ES as a second procedure increases the overall cost, length of stay, and complication rate, compared to LCBDE [16].
Conclusion In our opinion, the optimum management of CBD stones requires laparoscopic cholecystectomy and clearance of the
CBD during the same anesthesia in children, with preservation of the Oddi sphincter. Our 72 % success rate with per-operative cholangiography is a satisfying result, but could be upgraded by the development of LCBDE in cooperation with our pediatric gastroenterologists.
Disclosures Muller C. O, Boimond M. B, Rega A, Michelet D, El Ghoneimi A, and Bonnard A have no conflicts of interest or financial ties to disclose.
References 1. Debray D, Franchi-Abella S, Irtan S, Girard M (2012) Cholelithiasis in infants, children and adolescents. Presse Med 41: 466–473 2. Paris C, Bejjani J, Beaunoyer M, Ouimet A (2010) Endoscopic retrograde cholangiopancreatography is useful and safe in children. J Pediatr Surg 45:938–942 3. Rocca R, Castellino F, Daperno M, Masoero G, Sostegni R, Ercole E, Lavagna A, Barbera C, Canavese F, Pera A (2005) Therapeutic ERCP in paediatric patients. Dig Liver Dis 37: 357–362 4. Varadarajulu S, Wilcox CM, Hawes RH, Cotton PB (2004) Technical outcomes and complications of ERCP in children. Gastrointest Endosc 60:367–371 5. Otto AK, Neal MD, Slivka AN, Kane TD (2011) An appraisal of endoscopic retrograde cholangiopancreatography (ERCP) for pancreaticobiliary disease in children: our institutional experience in 231 cases. Surg Endosc 25:2536–2540 6. Shah RS, Blakely ML, Lobe TE (2001) The role of laparoscopy in the management of common bile duct obstruction in children. Surg Endosc 15:1353–1355 7. Bonnard A, Seguier-Lipszyc E, Liguory C, Benkerrou M, Garel C, Malbezin S, Aigrain Y, de Lagausie P (2005) Laparoscopic approach as primary treatment of common bile duct stones in children. J Pediatr Surg 40:1459–1463 8. Chan S, Currie J, Malik AI, Mahomed AA (2008) Paediatric cholecystectomy: Shifting goalposts in the laparoscopic era. Surg Endosc 22:1392–1395 9. Metreweli C, So NMC, Chu WCW, Lam WWM (2004) Magnetic resonance cholangiography in children. Br J Radiol 77:1059– 1064 10. Menon S, Patel B, Saekang E, Thomas G, Soundappan S, Shun A (2011) Laparoscopic exploration of the common bile duct to relieve choledocholithiasis in children. Pediatr Surg Int 27:537– 540 11. Tannuri ACA, Leal AJG, Velhote MCP, Gonlc¸alves MEP, Tannuri U (2012) Management of gallstone disease in children: a new protocol based on the experience of a single center. J Pediatr Surg 47:2033–2038 12. Vrochides DV, Sorrells DL Jr, Kurkchubasche AG, Wesselhoeft CW Jr, Tracy TF Jr, Luks FI (2005) Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children? Arch Surg 140: 359–361 13. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM (1996) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335:909–918 14. Stro¨mberg C, Luo J, Enochsson L, Arnelo U, Nilsson M (2008) Endoscopic sphincterotomy and risk of malignancy in the bile
123
Surg Endosc ducts, liver, and pancreas. Clin Gastroenterol Hepatol 6:1049–1053 15. Osanai M, Maguchi H, Takahashi K, Katanuma A, Yane K, Kaneko M, Hashigo S, Katoh S, Harada R, Katoh R, Tanno S (2011) Safety and long-term outcomes of endoscopic papillary balloon dilation in children with bile duct stones. Gastrointest Endosc 73:619–623
123
16. Riciardi R, Islam S, Canete JJ, Arcand PL, Stoker ME (2003) Effectiveness and long-term results of laparoscopic common bile duct exploration. Surg Endosc 17:19–22
