Abstract
The use of on table cholangiogram (OTC) during laparoscopic cholecystectomy (LC) continues to be a debated topic within surgical practice. Current National Institute for Health and Care Excellence (NICE) guidelines do not advocate its routine use in adult patients, and there is scarce evidence for its use in paediatric cases. We aimed to analyse the outcomes of OTC during laparoscopic cholecystectomy to see if the NICE guidance holds true for children. A retrospective case note review was performed with IRB approval of all children who underwent laparoscopic cholecystectomy between February 2005 and November 2014. A total of 65 patients were identified, 41 female (63%) and 24 male (37%). The median age was 12 years (IQR 6). None of the patients underwent OTC during their LC. Instead, pre-operative ultrasound scan (USS) was performed in all cases. From the cohort, 5 patients (13%) showed abnormalities; 3 of which had a dilated common bile duct, and 2 of which had bile duct stones. All 5 patients went on to receive additional imaging, 2 patients underwent a repeat USS both of which were normal on review; 1 patient had an Endoscopic Retrograde Cholangio-Pancreatectography (ERCP), stent and follow-up Magnetic Resonance Cholangio-Pancreatograthy (MRCP) which was normal; 1 patient had an MRCP, ERCP with sphincterotomy and a follow-up USS which was normal; and 1 patient had an ERCP with follow-up USS which was also normal. In line with current NICE guidance for adults, our study indicates that patients with common bile duct (CBD) stones or a dilated CBD can be identified and managed prior to laparoscopic cholecystectomy. This would suggest that there is no requirement for OTC in children. Similar NICE guidance in Paediatrics may be necessary to avoid unnecessary intervention.
Highlights
Laparoscopic Cholecystectomy (LC) is the current best practice in the surgical management of gallstone disease in children [1] [2]; the use of on table cholangiography (OTC) for routine LC has not been adequately investigated despite it being a frequently debated topic within adult surgical literature [3].On table cholangiography (OTC) during LC has historically been advocated by surgeons to reduce bile duct injury, identify associated choledocholithiasis, and to avoid post-operative imaging such as Endoscopic Retrograde Cholangiopancreatogrophy (ERCP) [3]
The LC approach developed for adult surgery has been well adopted by paediatric surgeons in the UK, with retrospective studies strongly advocating its use over open cholecystectomy [8,9,10,11,12,13]
The benefits of LC over open cholecystectomy have been well established for paediatric cohorts, reducing costs, post-operative hospitalisation, complications, and analgesia use [12] [13]
Summary
Laparoscopic Cholecystectomy (LC) is the current best practice in the surgical management of gallstone disease in children [1] [2]; the use of on table cholangiography (OTC) for routine LC has not been adequately investigated despite it being a frequently debated topic within adult surgical literature [3]. On table cholangiography (OTC) during LC has historically been advocated by surgeons to reduce bile duct injury, identify associated choledocholithiasis, and to avoid post-operative imaging such as Endoscopic Retrograde Cholangiopancreatogrophy (ERCP) [3]. In opposition to routine adopters of OTC, arguments against its use include the increase in morbidity associated with additional anaesthetic time, increased procedure time and heightened departmental costs [3] [5]. LC is chosen to minimise use of analgesics, reduce complications and to improve cosmesis [1] [9]
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