Although diagnostic laparoscopy was practiced primarily by gynecologists between 1970 and 1990, the modern surge in laparoscopic surgery began with the development of laparoscopic cholecystectomy in adults. Reddick and Olsen were the first to report this technique; they compared their experience with laparoscopic and open cholecystectomy between September 1988 and April 1989.1 Since then, an explosion in minimally invasive surgical procedures has occurred. It is only natural that these new endoscopic techniques are now being applied to children.
Previously, cholelithiasis has been considered an infrequent disease in children. However, its recognition has markedly increased in the past two decades. Actually, it should be considered in the differential diagnosis for any child or adolescent with vague or colicky upper abdominal pain and particularly in children with associated risk factors (Table). One reason for the failure to include gallstones in the early evaluation of children with epigastric complaints has been emphasis on the former belief that cholelithiasis does not occur in the absence of hemolytic disease. However, a report in 1966 from Children's Hospital, Vanderbilt University Medical Center called attention to the association of nonhemolytic cholelithiasis and unexplained abdominal symptoms.2 This association was further emphasized in a 1980 report from the same institution.3 In that study of 92 children and teenagers undergoing cholecystectomy, 87% had nonhemolytic cholelithiasis. In addition, six patients presented with pancreatitis as a complication of cholelithiasis.
Largely due to the increased use of ultrasonography, biliary calculi are being detected more frequently in infants. Many of these babies have received total parenteral nutrition, which has been widely associated with the formation of gallstones. Whether the primary reason for the development of gallstones in these patients is total parenteral nutrition, the lack of enteral feeding, or both is currently unclear. In addition, the correct management for gallstones in this age group is not completely settled. Moreover, spontaneous resolution of gallstones without treatment has been reported.4'7 Therefore, it is not unreasonable to observe patients in this age group who do not appear symptomatic and in whom the gallstones are not radiopaque. Currently, the ideal period of observation is not known. Nevertheless, a period of 6 to 12 months of observation is not unreasonable in the asymptomatic infant. However, should the stones remain present and show no evidence of resolution, particularly if calcified, then cholecystectomy is indicated to prevent complications. Should gallstones be noted in a young patient on total parenteral nutrition, then observation until the total parenteral nutrition is stopped and enteral feedings are resumed is justified to see if the stones will disappear within a reasonable time.
Risk Factors for Cholelithiasis in infants and Children
At Children's Hospital, Vanderbilt University Medical Center, a multidisciplinary study is being undertaken to follow neonates documented to have gallstones by ultrasound studies that are performed for other reasons. By following these patients closely, questions about the natural history of cholelithiasis in infancy may be answered.
Children - Age 2 to 12 Years
Nonhemolytic cholelithiasis is occurring more often in this age group than previously reported. At Children's Hospital, Vanderbilt University Medical Center, at least 16 children 2 to 12 years of age have been diagnosed with gallstones in the past 3 years.
Some children in this group have associated diseases causing gallstones. Conditions such as short bowel syndrome, ileocolic resection, prolonged total parenteral nutrition, and biliary tract anomalies may predispose to development of gallstones. However, other children have developed biliary calculi for unknown reasons, and the stones were documented by ultrasonography performed for unrelated symptoms. Symptomatic young children frequently are unable to localize pain to the upper abdomen or right upper abdominal quadrant, thereby delaying diagnosis for months and even years.
Following discovery of gallstones, these children are a little easier to manage in that cholecystectomy is recommended for those with symptoms and for those with radiopaque stones. When calculi are documented as an incidental finding on ultrasonography, a short period of observation of 3 to 6 months is not unreasonable. However, should the stones persist, then cholecystectomy is again recommended to prevent complications as acute cholecystitis and biliary pancreatitis have been seen in this age group.
Adolescents and Teenagers
In this older group, the symptoms and physical findings are similar to those found in adults. The pain is often subcostal and localized. Nausea and vomiting with intolerance to fatty foods also may be associated with the pain. Specific risk factors are found including female predominance, a history of pregnancy, obesity, and a family history of gallbladder disease.
In this teenage group, abdominal pain usually rather early leads to ultrasonography and subsequent documentation of gallstones as the etiology for the complaints. Therefore, cholecystectomy is indicated once the diagnosis is confirmed as complications such as biliary pancreatitis and acute cholecystitis are prevalent in these older children.
Sickle cell anemia and hereditary spherocytosis are the two diseases that account for the majority of hemolytic cholelithiasis. The incidence of gallstones in children with thalassemia major may be decreasing because of a hypertransfusion regimen.8
The incidence of cholelithiasis in children with sickle cell disease has been reported between 10% to 37%.911 In one study, 12% were affected in the 2- to 4'year age group whereas 42% were noted to have gallstones by age 15 to 18 years.12 Forty percent to 60% of children with spherocytosis will develop gallstones.13,14 Therefore, with hemolytic diseases and abdominal pain, an abdominal ultrasound should be performed to evaluate the possibility of cholelithiasis as the etiology for the complaints. In one study of children with sickle cell disease, there was a mean number of 10.24 hospitalizations and 25.35 ambulatory visits in patients with gallstones compared with a mean of 4.26 hospitalizations and 13.41 ambulatory visits when gallstones were not present.15 Moreover, a recent report indicates an increased referral for laparoscopic cholecystectomy in patients with sickle cell disease, even without symptoms.16 The reason for this aggressive approach is to prevent complications from cholelithiasis in this fragile group of patients.
The standard treatment for cholelithiasis has been cholecystectomy. A multicenter study in adult patients investigated dissolution therapy with oral administration of chenodeoxycholic acid for 6 months. A complete gallstone dissolution rate of only 13% was noted after 24 months.17 Extracorporeal shockwave lithotripsy also has been reported with 90% success in adults.18 Unfortunately, in the study, only 28% of adults seen with gallstones qualified for the lithotripsy protocol. A subsequent multicenter trial reported only a 21% resolution rate in 6 months.19 Although lithotripsy does avoid a surgical procedure, the duration of treatment, high cost, and a 50% risk of recurrent gallstones within 5 years are significant disadvantages for this nonoperative modality.20 Moreover, pigmented stones would be excluded from shockwave therapy. In addition, children have not been included in either the dissolution or lithotripsy trials.
Open cholecystectomy had been the standard method for gallbladder removal until 3 years ago. With the development of laparoscopic cholecystectomy in adults, the principles of this technique are now being applied to children with good success and minimal morbidity.
The major advantages to most laparoscopic procedures over open techniques are reduced hospitalization, decreased discomfort, faster return to routine activities such as school, athletic participation, or play, and an improved cosmetic result. These advantages occur because of less muscle disruption due to the small incisions and less trauma to the tissues, which results in minimal discomfort and ileus, contributing to a faster recovery from the procedure. These benefits also appear to apply to laparoscopic cholecystectomy in children.
Most patients are admitted to the hospital on the day of the procedure and are discharged the following day. For those with sickle cell disease, preoperative transfusions are still important to elevate the hematocrit level above 25% to 30%. In addition, preoperative hydration also is necessary to reduce the potential for sickling from dehydration. Therefore, these children are usually admitted the night before the operation for intravenous hydration and transfusions when indicated.
The patient is placed supine on the operating table with two video monitors located at the head of the table. The surgeon stands to the patient's left with the first assistant standing to the right. The scrub nurse stands to the right of the first assistant and the camera holder to the left of the surgeon (Figure 1 ). Four small incisions are used. A 1-cm incision is placed in the umbilicus for insertion of a 1-cm cannula through which the telescope is inserted for visualization. The 0° forward viewing telescope is then connected to the camera and the image visualized on the video monitors.
Three other 5-mm ports are used, each requiring a 5 -mm incision with each cannula being inserted under laparoscopic visualization. One port is located in the inguinal crease on the right side. A second port is placed over the gallbladder on the right and a third in the left epigastric region (Figure 2).
Forceps are inserted through the two right-sided cannulas, and the gallbladder is grasped and rotated up over the liver, exposing the cystic and common ducts. The surgeon works through the left epigastric port. The cystic duct is identified and dissected carefully to ensure that it is not misidentified with the common bile duct (Figure 3).
Once the cystic duct is isolated, a cholangiogram is performed both to document the correct anatomy and to evaluate for common bile duct stones. If the cholangiogram is normal, two clips are placed on the cystic duct near its junction with the common duct, and one clip is fixed on the cystic duct near the gallbladder. The cystic duct is then divided between the second and third clips. In a similar fashion, the cystic artery is clipped and divided (Figure 4).
Having ligated and divided the cystic duct and cystic artery, the gallbladder is dissected in a retrograde fashion from its hepatic bed (Figure 5). Several instruments can be employed for this dissection, including a hook cautery, a spatula cautery, or endoscopic scissors, which also can be connected to an electrocautery. Following detachment from its hepatic bed, the gallbladder is extracted through the 1-cm umbilical cannula (Figure 6). If the gallbladder is too large for the cannula, the cannula is removed and the gallbladder extracted through the umbilical incision.
The liver bed and endoscopic clips are inspected carefully prior to removal of the cannulas, and the incisions are closed with subcuticular sutures. The children usually are admitted for overnight observation and discharged the following morning.
Figure 1. For laparoscopic cholecystectomy, two video monitors are placed at the head of the table for easy viewing by the surgeon and first assistant. The camera holder is usually to the surgeon's left while the scrub nurse is usually to the right of the first assistant. Figure 2. Four small incisions are made through which the cannulas are inserted. Three 5-mm incisions are made, and a 10-mm incision is placed in the umbilicus. A 10-mm camera is inserted through the umbilical incision, and 5-mm cannulas are placed through the other incisions. For the right lower quadrant incision and the epigastric incision, the actual position varies depending on the size of the patient. Figure 3. Following exposure of the triangle of Calot, the cystic duct is identified and exposed. Figure 4. Following cholangiography, the cystic duct is divided with two clips placed on the cystic duct near the junction with the common duct. In a similar fashion, the cystic artery is divided. Figure 5. The gallbladder is removed in a retrograde fashion. This dissection can be accomplished with electrocautery, scissors (shown in this diagram), or a combination of both. Figure 6. Having been detached from the liver, the gallbladder is extracted through the 10-mm umbilical cannula.
Our first laparoscopic cholecystectomy in a child was accomplished in June 1990; subsequently, a total of 27 have been performed.21 -22 The mean age was 12.3 years (median: 13 years). Twenty-one children were female, and 18 were white. Only six children had hemolytic disease: four had sickle cell disease and two girls had spherocytosis.
Five children, presented with acute cholecystitis as a complication of gallstones. Laparoscopic cholecystectomy was performed within 5 days of admission, and the average postoperative hospitalization was 2.5 days. Two patients underwent endoscopic retrograde cholangiopancreatography (ERCP) because of jaundice. At ERCP, there was no evidence of common duct stones in these two patients.
Twenty-two children underwent elective laparoscopic cholecystectomy with a mean postoperative hospitalization of 1 day. One teenager underwent the procedure as an outpatient and was discharged that evening. Twenty children were discharged on the first postoperative day, and one child left the hospital on the second postoperative day.
The mean operative time for children undergoing elective laparoscopic cholecystectomy was 106 minutes compared with 150 minutes for those following acute cholecystitis. No operative complications occurred, and long-term complications such as biliary leak or common duct stricture have not been noted.
Open Versus Laparoscopic Cholecystectomy
The 22 children who underwent elective laparoscopic cholecystectomy were compared with seven children who underwent open cholecystectomy during the same study period at Children's Hosptial, Vanderbilt Univesity Medical Center. Open cholecystectomy was performed primarily in the first 2 years of this study, but has not been used in the past year. Open cholecystectomy was preferred by surgeons who were not using the laparoscopic approach.
The study group undergoing open cholecystectomy was similar to the patients having elective taparo* scopic cholecystectomy. Two patients in the open group had hematologic disease compared with six in the laparoscopic group. The mean operative time was 110 minutes for the elective open procedure and 106 minutes for the elective laparoscopic operation.
Comparisons between the two groups were made in terms of postoperative hospitalization, postoperative discomfort, and cost to the patient. As mentioned, the mean postoperative hospitalization of children in the laparoscopic group was 1 day compared with 3.71 days for those children who had open cholecystectomy. The mean cost to the patient in the laparoscopic group for postoperative pain relief was $37.21 compared with $267.41 for the patients who underwent open cholecystectomy. Although it is difficult to compare postoperative pain management, this study would imply that there is reduced discomfort from the laparoscopic procedure.
A third area of comparison involved hospital costs to the two groups. The mean hospital cost for the patient who underwent laparoscopic cholecystectomy was $6596.77 compared with a mean charge of $5940.32 for the child having an open procedure. At least 41.3% of the charges to the patient in the laparoscopic group was due to operating room equipment and supplies compared with 20% in the open group. Therefore, although there was a shorter hospitalization and reduced discomfort, there was a slightly higher total cost to patients undergoing laparoscopic cholecystectomy. However, this increased cost was not statistically significant (P = .06).
Laparoscopic cholecystectomy represents an innovative approach for the removal of the gallbladder in children. It appears to have several advantages over the open procedure. However, it will be necessary to reduce the cost differential between the open and laparoscopic procedures, which will most likely occur with increased use of reusable laparoscopic equipment compared with the predominant use of disposable equipment presently. With the increased documentation of gallstones in children today, laparoscopic cholecystectomy should provide advantages for early cholecystectomy. However, it will be necessary for pediatric surgeons to continue to use good surgical judgment and expert care in performing laparoscopic procedures in young patients.
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Risk Factors for Cholelithiasis in infants and Children