The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis

Abstract

Background: In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP). Methods: From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay. Results: The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m2 and 27.4 kg/m2, respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group. Conclusions: Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

“…LCBDE is an alternative strategy with the advantage of providing definitive treatment with a single procedure, limiting anesthesia, and having the likelihood of overcoming functional distal obstructions (e.g., sphincter spasm and sludge) by glucagon administration, ductal flushing or dilation [ 5 ]. Recently, Pogorelić et al confirmed that LCBDE is safe and feasible in pediatric patients, avoiding papillotomy or fluoroscopy [ 6 ]. Therefore, the trend should be directed toward less ERCP in favor of LCBDE, provided LCBDE is performed in centers with dedicated teams and instrumentation [ 5 ].…”

“…In children, ERCP and laparoscopic exploration of the common bile duct (LCBDE) can be performed safely and effectively. Still, recent literature suggests that LCBDE should be a method of choice in pediatric patients [ 6 ]. Skilling in pediatric patients has been supported by collaborating with pediatric gastroenterologists, pediatric surgeons, adult gastroenterologists, anesthesiologists, and radiology staff.…”

Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of “New Technologies”

“…In case of complicated GB disease (choledocholithiasis, common bile duct dilatation, gallstone pancreatitis), ERCP is indicated to drain the biliary tree or to remove stones after sphincterotomy [33]. Recently, the literature suggests performing LCBDE instead of ERCP to provide a definitive treatment in a single procedure and reduce complications associated with the endoscopic operative approach (ERCP complication risk is 5-10%) [34][35][36]. Although there are conflicting previous reports, the pediatric DUCT criteria (common bile duct dilation, US choledocholithiasis, and total bilirubin ≥1.8 mg/dL) seem to estimate the risk of choledochal involvement with high accuracy (>76%), specificity (>78%), and negative predicted values (>79%) [10].…”

Association between Cholecystectomy and the Incidence of Pancreaticobiliary Cancer after Endoscopic Choledocholithiasis Management

“…However, conflicting results suggest a lack of direct association between CCY and hepatobiliary system cancers [ 16 , 17 ]. Meanwhile, laparoscopic cholecystectomy and common bile duct exploration (LCBDE) was shown to resolve this problem in one step without destroying the structure of Ampulla of Vater in the management of choledocholithiasis compared with CCY after ERCP [ 18 ]. The current evidence for the correlation between increased cancer risks in the pancreatic and hepatobiliary system and CCY or endoscopic sphincterotomy (ES) [ 19 ] is not completely clear.…”