Management of suspected common bile duct stones in children: role of selective intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography

Abstract

Background: Evidence for diagnostic accuracy and clinical efficacy of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones in children is sparse and unclear.

Methods: Retrospective analysis of 202 children who underwent laparoscopic cholecystectomy (LC) between 1996 and 2002 was performed. Forty-eight children had suspected CBD stones on clinical, biochemical, and radiologic grounds. Two clinical pathways, LC followed by ERCP (L-->E) versus ERCP followed by LC (E-->L) were compared.

Results: From the cohort of 202 patients, 154 did not have suspected CBD stones. Of the 48 patients that did have suspected stones, 2 management pathways were followed: (1) ERCP first: 14 of 48 patients (including 1 failed examination). Three yielded positive findings on ERCP. Ten had negative findings on ERCP, 3 of which went on to have a subsequent IOC. All 3 had negative IOC examination findings. (2) LC +/- IOC first: 34 of 48 patients. Twenty-eight had negative findings on IOC and had no further investigations. Three patients had positive IOC examination findings and went on to have postoperative ERCP. Two of these 3 patients were positive for CBD stones. The remaining 3 of 34 patients had LC with no IOC followed by ERCP. Only 1 of 3 patients yielded a positive examination finding on ERCP. Therefore, of the 168 patients that did not have IOC, only 1 stone (0.6%) would have been missed using the selective criteria. Of those that did meet the criteria for IOC, only 2 of 31 (6.5%) had positive examination findings. There were no adverse effects of a retained or passed stone during our study, nor where there complications in those who had a concomitant sphincterotomy (12 of 20 ERCP patients, mean follow-up of 4.2 years). IOC and ERCP findings correlated in all 6 of the patients in which both procedures were performed.

Conclusions: Selective IOC with LC is an acceptable and safe initial approach in suspected CBD. Most CBD stones in children pass spontaneously. Endoscopic sphincterotomy appears to be safe with no long-term sequelae.