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Rauh J, Dantes G, Wallace M, Collings A, Sanin GD, Cambronero GE, Bosley ME, Ganapathy AS, Patterson JW, Ignacio R, Knod JL, Slater B, Callier K, Livingston MH, Alemayehu H, Dukleska K, Scholz S, Santore MT, Zamora IJ, Neff LP. Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study. J Pediatr Surg 2024; 59:389-392. [PMID: 37957103 DOI: 10.1016/j.jpedsurg.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. METHODS A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. RESULTS Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05). CONCLUSION Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jessica Rauh
- Wake Forest School of Medicine, Winston Salem, USA.
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- Wake Forest School of Medicine, Winston Salem, USA
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2
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Keane OA, Ourshalimian S, O'Guinn M, Ing M, Odegard M, Ignacio R, Kelley-Quon LI. Increases in pediatric cholecystectomy during the COVID-19 pandemic: An interrupted time series analysis. Surgery 2024; 175:304-310. [PMID: 38036396 DOI: 10.1016/j.surg.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/05/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Historically, cholecystectomy is infrequently performed in children. Lifestyle changes, delays in healthcare access, and increases in childhood obesity occurred during the COVID-2019 pandemic. It is unclear whether these changes impacted pediatric gallbladder disease and the need for cholecystectomy. METHODS A retrospective study of children ≤18 years old undergoing cholecystectomy from January 1, 2016, to July 31, 2022, at a tertiary children's hospital was conducted. On March 19, 2020, a statewide mandatory coronavirus disease 2019 stay-at-home policy began. Differences in children undergoing cholecystectomy before and during the pandemic were identified using bivariate comparisons. An interrupted time series analysis identified differences in case volume trends. RESULTS Overall, 633 children were identified-293 pre-pandemic and 340 pandemic. A majority were female sex (76.3%) and Hispanic (67.5%), with a median age of 15 years (interquartile range: 13.0-16.0). Children who underwent cholecystectomy during the pandemic had significantly higher body mass index (28.4 versus 25.8, P = .002), and obesity (body mass index >30) was more common (45.3% versus 31.7%, P = .001). During the pandemic, significant increases in complicated biliary disease occurred-symptomatic cholelithiasis decreased (41.5% versus 61.8%, P < .001) and choledocholithiasis (17.9% versus 11.6%, P = .026), gallstone pancreatitis (17.4% versus 10.6%, P = .015), and chronic cholecystitis (4.7% versus 1.0%, P = .007) increased. The number of cholecystectomies performed per month increased during the pandemic, and on interrupted time series analysis, there was a significant increase in month-to-month case count during the pandemic (P = .003). CONCLUSION Cholecystectomy case volume significantly increased during the coronavirus disease 2019 pandemic, possibly secondary to increases in childhood obesity. Future studies are needed to determine whether this increased frequency of pediatric cholecystectomy is representative of broader shifts in pediatric health and healthcare use after coronavirus disease 2019.
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Affiliation(s)
- Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA.
| | | | - MaKayla O'Guinn
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Madeleine Ing
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Romeo Ignacio
- Department of Pediatric Surgery, Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Destro F, Pierucci UM, Durante E, Caruso AM, Girgenti V, Canonica CPM, Degrassi I, Campari A, Pellegrinelli A, Barisella M, Nebuloni M, Brunero M, Biganzoli EM, Calcaterra V, Pelizzo G. Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of "New Technologies". CHILDREN (BASEL, SWITZERLAND) 2023; 10:1771. [PMID: 38002862 PMCID: PMC10670818 DOI: 10.3390/children10111771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children. AIMS This study aims to describe current indications and timing for LC in pediatric patients. METHODS Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020-2023. RESULTS In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores. CONCLUSIONS Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent.
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Affiliation(s)
- Francesca Destro
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (F.D.); (U.M.P.); (E.D.); (C.P.M.C.); (M.B.)
| | - Ugo Maria Pierucci
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (F.D.); (U.M.P.); (E.D.); (C.P.M.C.); (M.B.)
| | - Eleonora Durante
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (F.D.); (U.M.P.); (E.D.); (C.P.M.C.); (M.B.)
| | - Anna Maria Caruso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (V.G.)
| | - Vincenza Girgenti
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (V.G.)
| | - Carlotta Paola Maria Canonica
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (F.D.); (U.M.P.); (E.D.); (C.P.M.C.); (M.B.)
| | - Irene Degrassi
- Department of Pediatrics, Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (I.D.); (V.C.)
| | - Alessandro Campari
- Department of Pediatric Radiology, Buzzi Children’s Hospital, 20154 Milan, Italy;
| | - Alessandro Pellegrinelli
- Pathology Unit, Department of Biomedical and Clinical Sciences, University of Milan, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.P.); (M.B.); (M.N.)
| | - Marta Barisella
- Pathology Unit, Department of Biomedical and Clinical Sciences, University of Milan, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.P.); (M.B.); (M.N.)
| | - Manuela Nebuloni
- Pathology Unit, Department of Biomedical and Clinical Sciences, University of Milan, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.P.); (M.B.); (M.N.)
| | - Marco Brunero
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (F.D.); (U.M.P.); (E.D.); (C.P.M.C.); (M.B.)
| | - Elia Mario Biganzoli
- Department of Biomedical and Clinical Sciences (DIBIC) & Data Science Research Center (DSRC), Unit of Clinical Research and Medical Statistics, Ospedale “L. Sacco” LITA Campus, University of Milan, 20122 Milan, Italy;
| | - Valeria Calcaterra
- Department of Pediatrics, Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (I.D.); (V.C.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Gloria Pelizzo
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (F.D.); (U.M.P.); (E.D.); (C.P.M.C.); (M.B.)
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy
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Ignacio RC, Kelley-Quon LI, Ourshalimian S, Padilla BE, Jensen AR, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Wang K. Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children. J Am Coll Surg 2023; 236:961-970. [PMID: 36786471 DOI: 10.1097/xcs.0000000000000650] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children. STUDY DESIGN A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05. RESULTS A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL. CONCLUSIONS Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.
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Affiliation(s)
- Romeo C Ignacio
- From the Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA (Ignacio)
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ (Padilla)
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco School of Medicine, and Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, CA (Jensen)
| | - Stephen B Shew
- Department of Pediatric General Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA (Shew)
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR (Lofberg)
| | - Caitlin A Smith
- Department of Pediatric General Surgery, Seattle Children's Hospital, Seattle, WA (Smith)
| | - Jonathan P Roach
- Department of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO (Roach)
| | - Samir R Pandya
- Department of Pediatric General and Thoracic Surgery, University of Texas Southwestern, Dallas, TX (Pandya)
| | - Katie W Russell
- Division of General Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT (Russell)
| | - Kasper Wang
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
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Destro F, Salerno R, Calcaterra V, Ardizzone S, Meroni M, Roveri M, Pierucci UM, Zaja A, Rizzetto F, Campari A, Vertemati M, Milani P, Pelizzo G. Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040760. [PMID: 37190009 DOI: 10.3390/children10040760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.
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Affiliation(s)
- Francesca Destro
- Department of Pediatric Surgery, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Raffaele Salerno
- Gastrointestinal and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, 20157 Milan, Italy
| | - Valeria Calcaterra
- Department of Pediatrics, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
| | - Sandro Ardizzone
- Gastrointestinal and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, 20157 Milan, Italy
| | - Milena Meroni
- Department of Pediatric Surgery, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Margherita Roveri
- Department of Pediatric Surgery, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Ugo Maria Pierucci
- Department of Pediatric Surgery, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Alberta Zaja
- CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), University of Milano, 20133 Milan, Italy
| | - Francesco Rizzetto
- Postgraduate School of Diagnostic and Interventional Radiology, University of Milan, via Festa del Perdono 7, 20122 Milan, Italy
| | - Alessandro Campari
- Department of Pediatric Radiology, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Maurizio Vertemati
- CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), University of Milano, 20133 Milan, Italy
| | - Paolo Milani
- CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), University of Milano, 20133 Milan, Italy
| | - Gloria Pelizzo
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy
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Boscarelli A, Schleef J. Difficult gall bladder in adolescents with cystic fibrosis and symptomatic cholelithiasis: What is the best treatment choice? J Pediatr Surg 2022; 57:485-486. [PMID: 35490052 DOI: 10.1016/j.jpedsurg.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Alessandro Boscarelli
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.
| | - Jürgen Schleef
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy; Chief of Surgical Department, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
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