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Management Of Complicated Biliary Disease In The Pediatric Population
*Andrea Doud1, *Logan Bond2, *Cynthia Downard2, *Mary Fallat2, *David Foley2, *Tiffany Wright2, *Sheldon Bond2
1University of Kentucky, Lexington, KY;2University of Louisville, Louisville, KY

Objective: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, determining the incidence and best treatment options.
Methods: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 algorithm were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High risk (HR) patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement (CBDE). Low risk (LR) patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase.
Results:695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. 457 were performed for stone disease (66%) (64 hemolytic). 236 (34.0%) were performed for biliary dyskinesia. 103 (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated). Figure 1 shows the treatment for the 103 patients with complicated gallbladder disease.In high risk patients, 28/47 (59.6%) underwent ERCP/sphincterotomy. In Low Risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required ERCP/sphincterotomy (p&lt 0.05). The indication for ERCP after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications.
Conclusion: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 CBDE will require ERCP and this should be strongly considered prior to cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative ERCP if needed.


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