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Laparoscopic approach as primary treatment of common bile duct stones in children
Arnaud Bonnard1, E Seguier-Lipszyc, C Liguory
1Department of Pediatric Surgery, Hôpital Robert Debré, AP-HP, Paris, 75019, France. arnaud.bonnard@rdb.aphp.fr
Insights
Laparoscopic common bile duct (CBD) exploration is effective for pediatric choledocholithiasis, clearing stones in most cases. Postoperative endoscopic sphincterotomy (ES) is an option for residual obstruction, making the laparoscopic approach a suggested primary treatment.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Minimally Invasive Surgery
Background:
- Choledocholithiasis management in children remains controversial.
- Laparoscopic cholecystectomy is standard for pediatric cholelithiasis.
- Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) have known complications and unknown outcomes in children.
Purpose of the Study:
- To evaluate the effectiveness and safety of a laparoscopic approach for managing choledocholithiasis in children.
- To determine the outcomes of laparoscopic management of common bile duct stones in pediatric patients.
Main Methods:
- A retrospective review of 126 children treated for cholelithiasis between 1996 and 2001.
- Analysis of 13 children (10.3%) managed for choledocholithiasis, including age, paraclinical data, laparoscopic management type, and outcomes.
- Laparoscopic cholecystectomy with intraoperative cholangiogram and common bile duct (CBD) exploration was performed.
Main Results:
- Twelve children underwent laparoscopic cholecystectomy and cholangiogram; choledocholithiasis was confirmed in 10.
- CBD flush with catheters successfully cleared stones in 6 children; 3 required postoperative ES for obstruction or pancreatitis.
- One conversion to open surgery was necessary; all children were symptom-free at an average 28-month follow-up.
Conclusions:
- Laparoscopic CBD exploration is a safe and effective primary treatment for pediatric choledocholithiasis during cholecystectomy.
- Two-thirds of pediatric choledocholithiasis cases were cleared laparoscopically.
- Postoperative ES is a viable option for residual obstruction, supporting the laparoscopic approach as the preferred initial management strategy.
Background:
Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure.
Patients And Method:
Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome.
Results:
The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months.
Conclusion:
Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.
