Management of the Pediatric Patient with Choledocholithiasis in an Era of Advanced Minimally Invasive Techniques

Abstract

The treatment algorithm for children with suspected choledocholithiasis is not well established because the breadth of minimally invasive surgery and endoscopic techniques continues to evolve. We reviewed our experience with common bile duct explorations (CBDEs) in order to detail the techniques used and describe the rate of complications of laparoscopic CBDE in children. As part of an Institutional Review Board-approved study, medical records were reviewed for all patients, 1 month to 21 years of age, undergoing a cholecystectomy at a large tertiary-care children's hospital over an 11-year period. Those undergoing an intraoperative cholangiogram (IOC) were documented, and operative reports and postoperative records were examined. Over 11 years, 464 cholecystectomies were performed, and an IOC was attempted on 174 patients with a 97% success rate (n=168). Of the patients who underwent a cholangiogram, 30% (n=52) had an obstructing stone. Laparoscopic CBDE was attempted in 50 patients with a conversion rate of 8%. Postoperatively, 3 CBDE patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for the following reasons: retained stone (n=1), persistent hyperbilirubinemia (n=1), and bile leak (n=1). Laparoscopic CBDE is a safe initial approach to choledocholethiasis and is successful at relieving the obstruction the majority of the time. The authors conclude that in situations where there is limited availability of ERCP, laparoscopic CBDE should be considered as a first step in the management of obstructive choledocholethiasis.