Terapie komplikované cholelitiázy u dětí

Therapy of Complicated Cholelithiasis in Children

Aim:
The number of children patients with cholelithiasis has been increasing over the last years. The aim ofthis work was to evaluate indication criteria, sonographic and ERCP findings (endoscopic retrograde cholangiopancreatography),surgical methods, complications and the risk factors in children operated on cholelithiasis.Material and methods: The five-year period of September 1998 to August 2003 has been evaluated retrospectively.The study included 48 children - 38 girls and 10 boys at the average age of 12.5 years (from three to 18 years).The retrospective analysis included anamnesis, results of laboratory examinations, findings during ultrasonography(USG) andERCP, surgical solution and the incidence of complications. Five children were affected by congenitalspherocytosis, one patient suffered from cystic fibrosis and another one from Wilson disease. Forty one children failed to display significant health problems in anamnesis, which might influence the incidence of lithiasis. Allchildren were examined in a previous period and treated by a gastroenterologist. The conservative treated,whenever initiated, proved to be unsuccessful. The hematological patients underwent a primary operation in anopen filed in cases, where splenectomy and cholecystectomy were simultaneously indicated. The children withcholedocholithiasis underwent ERCP with papillotomy and extraction of concretions before cholecystectomy.Results: Symptomatic cholecystolithiasis and the condition after endoscopic papillotomy with extraction ofconcretions and sludge were the indications for operation as well as cholecystolithiasis accompanying spherocytossin five children, hydrops of gallbladder in one and porcelain gallbladder in another child. The preoperationsonographic examination was performed in all children with the finding of solitary or multiple cholecystolithiasis.ERCP was indicated in suspected choledocholithiasis. ERCP was performed in 29 children, being accompaniedwith papillotomy in 24 children, and concretions in choledochus were removed in 15, while sludge was removed in8 and two of the children were introduced the stunt. Forty eight patients altogether were operated on: laparoscopywas applied in 39 patients and operation in an open field in nine. Thirty seven laparoscopic operations were finished,whereas two interventions were converted. The reason for the conversion in one case was a knee-shaped bendingof gallbladder with a suspected choledochus cyst and blind terrain due to severe pericholecystitis. In four childrenoperated on in the open field, splenectomy was made at the same time, in two others biopsy was taken from tissuesin the neighborhood of external biliary pathways. The mean period of hospitalization lasted 4.8 days afterlaparoscopy and 8.4 days after the open operation (including converted ones). Postoperation intraabdominalcomplications were not recorded. One girl with a non-diagnosed inborn syndrome of long QT interval suffered,after the operation, from heart fibrillation with required KPR. This cohort included a higher proportion of obesechildren. The higher incidence of extreme obesity among girls older than 11 years was not accompanied with anassociated disease.Conclusions: Cholecystectomy in children is indicated in choledocholithiasis, symptomatic cholecystolithiasisand lithiasis in splenectomy from hematological indications. Asymptomatic cholecystolithiasis detected by chancein small children should be indicated for more detailed observation. In cases of choledocholithiasis, ERCP withpapillotomy is made in the first period of time and choledochocystectomy follows in a minimal interval. A wellequipped workplace with personal experienced in endoscopic interventions in children and adults is the preconditionfor these interventions. Laparoscopic cholecystectomy is presently the method of choice in children. In casesof the blind operation field in laparoscopy the operation is converted. Obesity in children is a risk factor for thedevelopment of cholelithiasis in children.

Key words:
cholelithiasis, cholecystolithiasis, obstruction icterus, cholecystectomy, ERCP, papillotomy, pancreatitis