R. E. Overman1, L. Hsieh1, T. Thomas1, S. Gadepalli1, J. Geiger1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA
Introduction:
The treatment of choledocholithiasis in pediatric patients can be challenging, and the optimal approach has not been identified. Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the two interventions commonly utilized in the treatment of choledocholithiasis. We compare our experience with these two techniques in our institution.
Methods:
With the approval of the University of Michigan IRB, we identified 81 pediatric patients under 18 years of age with suspected choledocholithiasis who underwent laparoscopic cholecystectomy (LC) with IOC/CBDE or ERCP from May 1, 2006 to December 31, 2016. Primary outcomes analyzed were success of intervention and complications.
Results:
Of the 81 patients with suspected choledocholithiasis, 23 patients (28%) underwent an endoscopic intervention prior to LC [20 ERCP, 3 endoscopic ultrasound (EUS)]. Of patients who underwent EUS/ERCP first, 17 had stone or sludge cleared endoscopically, while 6 had normal common bile ducts without evidence of stones or obstruction. Of a total of 34 patients who underwent endoscopic intervention, there were 5 with post-ERCP complications, including pancreatitis, bleeding requiring repeat EGD, and retained CBD stone requiring repeat ERCP. Of the 58 (72%) patients who underwent laparoscopic intervention first, 37 had a negative IOC and required no further intervention, 2 could not have IOC completed, and 19 had IOC positive for choledocholithiasis. 15 patients underwent attempted CBDE, 8 of which were successful. None of the patients who underwent a successful CBDE suffered post-operative complications or required further procedures. Of the 7 patients in whom CBDE was unsuccessful, 5 underwent ERCP with stone extraction, 1 underwent ERCP with no evidence of CBD stone, and 1 had choledocholithiasis resolve without intervention. In our series, 1 patient suffered cystic duct leak after LC (1.2%).
Conclusion:
Patients with choledocholithiasis who underwent laparoscopic intervention first had fewer complications, and many also avoided a second anesthetic associated with the need for ERCP after LC. While our success rate remains moderate, we believe that with increased standardization, availability of the tools needed, and increased volume that the success rate will increase over time. Our evidence suggests that patients with suspected choledocholithiasis should undergo laparoscopic cholecystectomy first with IOC and CBDE if indicated, with ERCP reserved for patients whose ducts cannot be cleared laparoscopically.
