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Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction
Published on: March 25, 2022
Management of complicated biliary disease in the pediatric population
Andrea Doud1, Logan Bond2, Cynthia Downard2
1Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
Insights
Pediatric cholecystectomies for cholesterol stones and biliary dyskinesia are increasing. Complicated biliary disease, including choledocholithiasis and gallstone pancreatitis, requires careful consideration of endoscopic retrograde cholangiopancreatography before or after cholecystectomy.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Biliary Tract Disease
Background:
- Cholesterol stones and biliary dyskinesia are now the leading reasons for pediatric cholecystectomy, surpassing hemolytic disease.
- This study focuses on pediatric patients with complicated biliary disease, specifically choledocholithiasis and/or gallstone pancreatitis.
Purpose of the Study:
- To determine the incidence of complicated biliary disease in pediatric patients.
- To evaluate the optimal treatment strategies for these conditions.
Main Methods:
- A 15-year retrospective review of pediatric cholecystectomies at a single children's hospital.
- Data collected included patient factors, indications for surgery, and treatment outcomes.
- Complicated disease was defined by imaging-confirmed choledocholithiasis or gallstone pancreatitis.
Main Results:
- Out of 695 cholecystectomies, 103 (14.8%) had complicated biliary disease.
- High-risk patients (with choledocholithiasis or common bile duct enlargement) were more likely to require endoscopic retrograde cholangiopancreatography/sphincterotomy (59.6%) compared to low-risk patients (23.2%).
- No bile leak complications occurred in patients undergoing endoscopic retrograde cholangiopancreatography after cholecystectomy for choledocholithiasis.
Conclusions:
- The incidence of complicated pediatric biliary disease from cholesterol stones mirrors that in adults.
- Endoscopic retrograde cholangiopancreatography should be strongly considered for pediatric patients with imaging evidence of choledocholithiasis or common bile duct enlargement, potentially before cholecystectomy.
- Pediatric patients without radiographic evidence of common duct stones can undergo laparoscopic cholecystectomy, with postoperative endoscopic retrograde cholangiopancreatography reserved for cases where it is indicated.
Background:
Cholesterol stones and biliary dyskinesia have replaced hemolytic disease as the primary indication for pediatric cholecystectomy. This study looks at the cohort of pediatric patients with complicated biliary disease, defined as choledocholithiasis and/or gallstone pancreatitis, to determine the incidence and best treatment options.
Methods:
A retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children's hospital was performed. Patient factors, indications for cholecystectomy, and final treatment were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High-risk patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase.
Results:
A total of 695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. Of the 695 cholecystectomies, 457 were performed for stone disease (66%) (64 hemolytic) and 236 (34.0%) were performed for biliary dyskinesia. Hundred and three (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated disease). In high-risk patients, 28/47 (59.6%) underwent endoscopic retrograde cholangiopancreatography/sphincterotomy. In low-risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required endoscopic retrograde cholangiopancreatography/sphincterotomy (P < .05). The indication for endoscopic retrograde cholangiopancreatography after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications.
Conclusion:
The incidence of pediatric complicated biliary disease due to cholesterol stones is equal to that of adults. These data suggest that a patient with imaging evidence of choledocholithiasis or common bile duct enlargement may require endoscopic retrograde cholangiopancreatography, dependent on clinical course, and this should be strongly considered before cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative endoscopic retrograde cholangiopancreatography if needed.
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