Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY.
Surgery. 2022 Mar;171(3):736-740. doi: 10.1016/j.surg.2021.09.041. Epub 2021 Nov 27.
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.
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.
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.
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.
胆固醇结石和胆汁运动障碍已取代溶血性疾病成为小儿胆囊切除术的主要适应证。本研究观察了一组复杂胆道疾病的儿科患者，这些患者的定义为胆总管结石和/或胆石性胰腺炎，以确定其发病率和最佳治疗选择。
对 15 年来在一家独立的儿童医院外科病房接受胆囊切除术的所有患者进行了回顾性分析。记录患者因素、胆囊切除术适应证和最终治疗情况。复杂胆囊疾病定义为影像学证实的胆总管结石或胆石性胰腺炎。高危患者为影像学显示明确的胆总管结石或伴有胆总管扩张的胆石症。低危患者为影像学检查有胆石症或胆囊泥沙样结石，同时伴有胆红素和/或脂肪酶升高。
在 15 年的时间内共进行了 695 例胆囊切除术。平均患者年龄为 13.4 岁。在 695 例胆囊切除术中，457 例（66%）因结石病而行胆囊切除术（64 例为溶血性疾病），236 例（34.0%）因胆汁运动障碍而行胆囊切除术。103 例（所有胆囊切除术的 14.8%，结石病的 22.5%）出现胆总管结石和/或胆石性胰腺炎（复杂疾病）。在高危患者中，47 例中有 28 例（59.6%）行内镜逆行胰胆管造影/括约肌切开术。在低危患者（无胆总管结石或胆管扩张）中，56 例中有 13 例（23.2%）需要行内镜逆行胰胆管造影/括约肌切开术（P<0.05）。胆囊切除术后行内镜逆行胰胆管造影的指征为胆总管结石，且这些患者均无胆漏并发症。
由于胆固醇结石引起的小儿复杂胆道疾病的发病率与成人相同。这些数据表明，对于有影像学证据表明存在胆总管结石或胆管扩张的患者，可能需要行内镜逆行胰胆管造影术，取决于临床病程，在进行胆囊切除术之前应强烈考虑这一点。对于没有这些影像学发现的患者，可以行腹腔镜胆囊切除术，如果需要，术后可进行内镜逆行胰胆管造影术。
