"Rendezvous" Procedure in Children with Cholecysto-Choledocholithiasis

Making common duct exploration common-balloon sphincteroplasty as an adjunct to transcystic laparoscopic common bile duct exploration for pediatric patients

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has well-established benefits for managing pediatric choledocholithiasis. However, providers increasingly favor ERCP pre-or-post laparoscopic cholecystectomy (ERCP+LC) due to perceived complexity of LCBDE. We refined a stepwise method employing wire-ready balloon dilation of the Sphincter of Oddi. This study compares outcomes of balloon sphincteroplasty (LCBDE+BSP) with standard transcystic LCBDE (LCBDE-STD) and ERCP+LC.

METHODS

We performed a retrospective chart review of pediatric patients who underwent LCBDE-STD and LCBDE+BSP since 2018. A report of consecutive choledocholithiasis patients prior to 2018 yielded an ERCP+LC cohort. Age, operative time, complications, and length of stay (LOS) were compared across all groups. Success rate and fluoroscopy time were compared between LCBDE groups.

RESULTS

44 patients were identified (14:LCBDE-STD; 15:LCBDE+BSP; 15:ERCP+LC) . There was no difference in patient age or BMI. Operative time was longer in the LCBDE+BSP group (p =< 0.05). ERCP+LC demonstrated increased LOS (4.36 ± 2.78 vs 1.31 ± 0.93; p =< 0.05) and complications compared to LCBDE groups including three stent placements and one stent migration. LCBDE+BSP had a higher success rate than LCBDE-STD (100% vs 78%; p = 0.06). The three patients who failed LCBDE-STD required postoperative ERCP. Average fluoroscopy time was not significantly impacted by addition of sphincteroplasty.

CONCLUSION

Incorporating LCBDE into standard management of pediatric choledocholithiasis reduces LOS and avoids additional invasive procedures regardless of the specific technique employed. This stepwise approach to wire-ready cholangiography with balloon sphincteroplasty is a viable method for LCBDE that utilizes techniques familiar to pediatric surgeons and provides definitive management under a single anesthetic.

LEVEL OF EVIDENCE

Level III.

Laparo-Endoscopic Rendez-Vous in the Treatment of Cholecysto-Choledocolithiasis in the Pediatric Population

OBJECTIVES

The incidence of choledocolithiasis is reported to be increasing in children. As for the adult population, several different therapeutic strategies have been described, however it is unclear which of those should be considered the gold standard. There is evidence-based literature in adults that supports a combined "rendez-vous" endoscopic retrograde cholangiopancreatography-laparoscopic cholecystectomy technique. This allows management of the choledocholithiasis during the same anesthetic episode as the cholecystectomy. By contrast, there are just two case reports in children reporting this approach. The aim of this study is to report our experience with this technique in a series of children with choledocholithiasis.

METHODS

All patients who underwent the "rendez-vous technique" at our institution between 2009 and 2020 were reviewed and evaluated for outcomes and complications.

RESULTS

Eleven children with cholecysto-choledocholithiasis were evaluated: the procedure was successful in 10 whereas in one patient it was aborted due to technical difficulties. All patients resolved their clinical condition without major complications.

CONCLUSION

To our knowledge, this is the first consistent series of "rendez-vous technique" in the pediatric population, proving its feasibility and safety.

Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.

Laparoscopic-Endoscopic "Rendezvous" Procedure in Pediatric Gastrointestinal Surgery-Case Series

Laparoscopic–endoscopic “rendezvous” procedures were introduced in surgery for common bile duct stone treatment but are now widely used in other fields of abdominal surgery. An endoscopist navigates a surgeon during the same operative procedure and, thus, enables a better visualization of the location, resection margins, bleeding control, less thermal damage, etc. Here, we present case series of 11 patients that were treated using a “rendezvous” procedure for gastrointestinal lesions on different parts of the gastrointestinal tract such as juvenile polyps on the colon (transversum, ascendens, cecum, sigma), leiomyomatosis of the stomach, Peutz–Jeghers intestinal polyposis, hyperplastic gastric polyp, ectopic pancreatic tissue in the stomach, gastric trichobezoar, and gastric schwannoma. “Rendezvous” procedures are suitable for intestinal lesions that could not be resected endoscopically due to their size, morphology and/or location. In our experience this procedure should be used for endoscopically unresectable lesions as it decreases the time of surgery, possibility of iatrogenic injury, bleeding and technical inability. Furthermore, this procedure has been shown to better navigate the surgeon during laparoscopic surgery, especially in treating polyps in particularly difficult locations such as the duodenum or cecum, and it decreases conversion rates. However, conversion is sometimes necessary, in order to assure all oncological principals are respected, and the best option in some cases.