Introduction
Pediatric gallbladder disease is a common ailment and appears to have a rising prevalence. , While previously found predominantly in patients with hematologic disorders that resulted in the formation of pigmented stones, the rise of childhood obesity has increased gallstones and associated complications in children and teenage patients. Advances in critical care for pediatric patients of all ages have also resulted in higher rates of acalculous cholecystitis. While laparoscopic cholecystectomy remains the dominant surgical intervention for symptomatic cholelithiasis and cholecystitis, innovative technologies including the use of robotics and fluorescent dyes (principally indocyanine green, ICG) are increasingly being employed in the pediatric population.
Etiology
Cholelithiasis
Gallstones are most often formed in the gallbladder, and less commonly directly in the intra- or extrahepatic bile ducts. Gallstones are classified according to their composition: pigment stones, cholesterol stones, or mixed. While pigmented stones are typically found in patients with hemolytic diseases, cholesterol stones are caused by an increased concentration of cholesterol in the bile from various genetic and environmental factors. Cholesterol levels are affected by synthesis, enterohepatic recirculation, and dietary intake.
Gallstones can result in biliary colic, cholecystitis, choledocholithiasis, cholangitis, and gallstone pancreatitis, although most commonly, gallstones are asymptomatic. Cholelithiasis is still the most common indication for cholecystectomy in pediatric patients (68.4% in 66 studies from a meta-analysis). Most studies argue that cholelithiasis has increased in incidence in children in recent years; the incidence of cholecystectomies ranges from 3 to 13 per 100,000 person years. ,
As in adult populations, risk factors for cholelithiasis in children include obesity, metabolic syndrome, hemolytic disease, ileal resections, cystic fibrosis, cholestatic medications (such as ceftriaxone or oral contraceptives), and the use of total parenteral nutrition. While gallstones in the pediatric population were historically most associated with hemolytic diseases, obesity has now become the primary risk factor, especially among teenage patients. , Increasing rates of obesity in children have correlated with increasing rates of hospitalization for pediatric cholelithiasis.
Infants with cholelithiasis have different risk factors, which can include cholestatic medications or disease processes, total parenteral nutrition, sepsis, prematurity, malabsorptive gastrointestinal conditions, or other etiologies such as congenital heart disease. Conservative management with ursodeoxycholic acid and nutritional management can be a treatment option in these patients, although cholecystectomy should be considered if this fails.
Cholecystitis
Cholecystitis is most commonly secondary to gallstones in both the adult and pediatric populations. Cholecystitis was found to be the second most common indication for cholecystectomy in children after cholelithiasis in a meta-analysis (59.2% of cases from 53 studies).
Acalculous cholecystitis is most commonly found in critically ill patients and is also associated with bacterial and parasitic infections. It can also be associated with viruses, such as Epstein–Barr virus and hepatitis A. , There is evidence that worldwide, a higher proportion of pediatric patients have acalculous rather than calculous cholecystitis (mostly secondary to infections) compared to adults. Acalculous cholecystitis may also result from immune-mediated disorders, such as Kawasaki disease, systemic lupus erythematous, and nephrotic syndrome. ,
Chronic cholecystitis is likely more prevalent in pediatric patients compared to adult patients, as symptoms may be underappreciated and there may be referral delays. In a single-center retrospective study of all pediatric cholecystectomies performed from 2010 to 2015, 55% of the 170 patients identified had chronic symptoms for an average of 7.4 months and pathology identified chronic cholecystitis in 87% of patients. Another single-center retrospective study from 2005 to 2010 found that 80% of patients had pathologic evidence of chronic cholecystitis. The authors argue that surgeons should consider early cholecystectomy for patients with symptomatic cholelithiasis or cholecystitis.
Treatment of acute cholecystitis consists of antibiotic therapy and cholecystectomy. If cholecystectomy is not offered due to significant disease severity or comorbidities, or if the surgeon does not feel comfortable performing cholecystectomy based on patient size or age, biliary drainage via a percutaneous cholecystostomy tube can be offered. In adults, the Tokyo Guidelines 2018 offers international consensus treatment guidelines for both acute cholecystitis and cholangitis. Key steps include performing diagnostic assessments every 6–12 hours with ultrasound followed by computerized tomography (CT) or hepatobiliary iminodiacetic acid (HIDA) scan until a diagnosis is made; using the severity assessment criteria to assess severity repeatedly at diagnosis and within 24 and then 48 hours after diagnosis; starting antibiotic treatment; fluid replacement, fasting, and electrolyte replacement; and considering laparoscopic cholecystectomy within 72 hours of symptom onset. E. coli is the most common organism isolated from adult patients with bacteremia from biliary infection (35%–62%). Recommended antibiotic regimens include ampicillin/sulbactam (if <20% resistance rate), cephalosporin-based therapy and metronidazole, or piperacillin/tazobactam (especially in more severe cases). While these can be extrapolated to pediatric patients, no established consensus guidelines exist for pediatric patients.
Hydrops
In pediatric patients, gallbladder hydrops has most commonly been associated with Kawasaki disease, although there are case reports associated with IgA vasculitis, Henoch-Schoenlein syndrome, and some infections, such as Epstein–Barr virus.
Functional Disorders of the Gallbladder
Disorders of gallbladder ejection (biliary dyskinesia), including either impaired or overrapid gallbladder emptying, comprise a poorly understood but important subset of functional gallbladder disease and associated pain. Definitions for biliary dyskinesia are variable, but usually include a measurement of gallbladder ejection using nuclear scintigraphy with an ejection fraction <35%. Hyperkinesia has been described as ejection fraction >90%.
Functional disorders of the biliary system comprise a higher proportion of indications for cholecystectomy in pediatric patients compared to adults. Biliary dyskinesia incidence is widely variable within the United States, and extremely low in other parts of the world, regardless of geographic location, patient demographics, or diet. In the United States, rates are highest among overweight adolescent white females. Biliary dyskinesia was the indication for 28.8% of cholecystectomies among 34 studies in a meta-analysis (although the definition of dyskinesia varied across studies). There is no accepted medical management of functional disorders of the gallbladder, although some have used ursodeoxycholic acid, antispasmodics, and neuromodulators. Instead, cholecystectomy is typically offered, especially if symptoms are severe.
In adults, functional disorders of the gallbladder are defined by biliary pain in the absence of cholelithiasis or other structural pathology, according to the Rome IV working group criteria. Biliary pain is pain located in the epigastrium or right upper quadrant and builds to a steady state that lasts 30 minutes or longer, occurs at different intervals (not daily), can disrupt daily activities, and is not related to bowel movements or relieved by postural changes or acid suppression. Normal lab values (liver enzymes, bilirubin, amylase/lipase) and a low ejection fraction on gallbladder scintigraphy (<35%) are supportive criteria for diagnosis of biliary hypokinesia. However, a low ejection fraction is not diagnostic alone, as this can be seen in other functional gastrointestinal disorders.
Outcomes after cholecystectomy for pediatric biliary hypokinesia vary widely. Short-term outcomes appear improved, with at least a partial clinical response in 63%–100% of patients and complete symptom resolution in 44%–100% of patients. However, several single-institution studies have reported an initial improvement in symptoms followed by worsening symptoms among 35%–65% of patients at 2–5 years of follow-up. In a retrospective review of 678 patients across 16 institutions who underwent cholecystectomy for biliary hypokinesia, 35% of patients had persistent symptoms at a mean follow-up time of 21 days. Multivariate analysis identified nonwhite race and the presence of psychiatric comorbidities as risk factors for ongoing postoperative symptoms.
Patients with biliary hyperkinesia, defined as biliary colic symptoms with an HIDA ejection fraction of >80%, may also be helped by cholecystectomy, although case numbers are small and long-term outcome data are lacking. Patients are also predominantly obese Caucasian teenage females. , In one study, most of these patients (82.4%) had chronic cholecystitis or cholesterolosis on gallbladder pathology. On 2-month follow-up of 13 patients who underwent cholecystectomy from a single-institution study, 50% reported ongoing symptoms. It is still unclear whether cholecystectomy is helpful in this population.
Complicating matters further, a subset of patients with normal HIDA scans (i.e., ejection fraction 35%–80%) but with pain during cholecystokinin injection at the time of the HIDA scan have been found to have high rates of chronic cholecystitis on pathology (62.5%) with >80% of patients experiencing resolution of symptoms after cholecystectomy in a single-institution study.
Polyps
Gallbladder polyps are rare in childhood and can be asymptomatic or present with right upper quadrant pain. They are typically identified as a fixed echogenic lesion attached to the gallbladder wall on ultrasound. They may be pedunculated or sessile and lack an acoustic shadow. Gallbladder polyps may be primary or secondary (etiologies include Peutz-Jeghers, Marshall-Smith syndrome, metachromatic leukodystrophy, or pancreaticobiliary malfunction). , In adults, polyps are common and most are harmless cholesterol polyps. Hyperplastic and adenomatous polyps are the next most common types. A subset of polyps is malignant, although these are more common in adults with no published reports of malignancy in pediatrics to date.
The natural history of gallbladder polyps in children remains unknown, and there are no clear guidelines. There is some evidence that pediatric gallbladder polyps may resolve spontaneously on follow-up. In adults, cholecystectomy is recommended in patients with gallbladder polyps >10 mm in size with a genetic predisposition to malignancy (or >15 mm in all other cases), or if there is rapid growth. Cholecystectomy should be considered in all pediatric patients with polyps, especially if symptomatic, multiple polyps, a polyp >10 mm, or if the polyp experiences rapid growth. Ultrasound is sufficient for follow-up.
Adenomyomatosis
Adenomyomatosis is hypertrophy of the gallbladder mucosal epithelium that invaginates into a thickened muscularis propria, forming intramural diverticula called Rokitansky-Aschoff sinuses. It is rare but more common in adults and the incidence increases with age. However, there are case reports in children, including neonates. In case reports, the most common symptom was abdominal pain, but some are found incidentally. Contrast-enhanced ultrasound may aid in the diagnosis of adenomyomatosis. Cholecystectomy is recommended if symptomatic; no guidelines exist for asymptomatic patients but monitoring rather than cholecystectomy would be reasonable. In adults, there are some reports of an association with cancer, but a link has not been proven, and the pathophysiology and natural history of adenomyomatosis in pediatric patients is unknown.
Complications from Gallstones
Gallstones can lead to choledocholithiasis or gallstone pancreatitis. One meta-analysis found that 15.8% of cholecystectomies were done for choledocholithiasis (among 37 studies). In a single-institution study of 695 pediatric cholecystectomies from 2003 to 2018, 22.5% of patients had complicated biliary disease, defined as choledocholithiasis, common bile duct dilation, or gallstone pancreatitis, which is similar to the incidence of complicated biliary disease in adults.
Choledocholithiasis
A recent multicenter retrospective study found that 22.7% of patients who underwent cholecystectomy had a diagnosis of choledocholithiasis on MRCP, ERCP, or intraoperative cholangiogram. The “DUCT” Criteria are predictive factors for choledocholithiasis in pediatric patients, and include (1) a dilated common bile duct ≥6 mm, (2) ultrasound with choledocholithiasis, and (3) total bilirubin ≥1.8 mg/dL. Two or three of these factors have a high predictive capacity for choledocholithiasis, while patients with one of none of these factors (and thus at a minimal risk for choledocholithiasis) can forego additional testing such as MRCP or procedures such as ERCP or intraoperative cholangiogram. Of note, high liver enzymes (aspartate aminotransferase/alanine aminotransferase), which are commonly elevated in adults with choledocholithiasis, were not predictive in this pediatric model.
Gallstone Pancreatitis
Approximately 10% of cholecystectomies in children are performed for gallstone pancreatitis. Traditionally, 10%–30% of pancreatitis in children is from biliary disease, although this proportion may be rising with the increasing incidence of gallstones in this population. Approximately 30% of biliary obstruction in children is from sludge, rather than stones. It is unclear whether this is truly due to sludge/microlithiasis or whether the sludge is indicative of a stone that passed, but sludge alone should not dissuade the practitioner from considering biliary tract disease as the cause of pancreatitis.
Recurrence rates are reported up to 40%; thus, cholecystectomy is recommended after an initial episode of gallstone pancreatitis. In a multicenter cohort analysis from 2010 to 2017, patients who underwent late cholecystectomy (after the index admission for gallstone pancreatitis) had a 33% rate of return to the ED for pain and 60% of patients who underwent cholecystectomy more than 6 weeks after index admission had recurrence. They argue that early cholecystectomy (during the index admission) had a 90% relative risk reduction of recurrent pancreatitis. There was no difference in outcomes in patients who underwent preoperative ERCP.
Other
In a meta-analysis, less than 1% of pediatric cholecystectomies were performed for cholangitis. While gallbladder perforation is seen in adults, particularly among patients with diabetes or vasculitis, it is extremely rare in pediatric patients. Blunt trauma can cause gallbladder perforation in pediatric patients; approximately eight cases of isolated gallbladder injury have been published in the literature, from mechanisms such as handlebar injuries and road traffic accidents. Gallbladder volvulus can also occur, although is rare, even in adults, with only case reports in children. Work-up is typically nonspecific, although the HIDA scan may be abnormal if the cystic duct is obstructed. Gallstone ileus is essentially unheard of in pediatric patients.
Special Populations
Hematologic Disorders
Patients with hematologic disorders, including sickle cell disease and hereditary spherocytosis, are at an increased risk of gallstone formation due to hyperbilirubinemia from hemolysis.
A prospective study in France among patients with sickle cell anemia demonstrated that gallstones may begin as early as 2.5 years of age and that by age 15, the cumulative risk of gallstones is 36%. In a retrospective cohort study of administrative claims dating from 2014 to 2018, 6.9% of patients with sickle cell disease had gallbladder disease, with 3.5% undergoing cholecystectomy. In a study of pediatric patients with sickle cell disease in Saudi Arabia, 75% of 153 patients developed cholelithiasis at a mean age of 7 years. Cholelithiasis increased with age and in those with higher levels of hemoglobin S and mean corpuscular volume. Some have advocated for elective cholecystectomy in patients with sickle cell disease and gallstones to prevent morbidity from choledocholithiasis or cholecystitis, but this is not a universal recommendation.
In patients with hereditary spherocytosis, cholecystectomy is recommended at the time of splenectomy if gallstones are identified (even if asymptomatic) to prevent further complications. However, in patients with hereditary spherocytosis with symptomatic cholelithiasis or cholecystitis who do not meet criteria for splenectomy, synchronous splenectomy is not indicated.
Neonatal
While neonatal jaundice prior to 2 weeks of age is common and due to transient unconjugated hyperbilirubinemia, cholestatic jaundice that persists is most commonly due to biliary atresia, inspissated bile syndrome, or neonatal choledocholithiasis. Neonatal cholelithiasis can be associated with choledochal cysts and other disorders of the biliary tree, hemolytic disorders, total parenteral nutrition and cholestatic medications, and malabsorptive gastrointestinal conditions. , Ischemic injury from congenital heart disease, vasculitis, or sepsis can also cause cholecystitis. Most neonatal patients with gallstones are asymptomatic and the gallstones may spontaneously resolve, but some can cause choledocholithiasis or cholecystitis.
Fetal
Fetal gallbladder sludge may be present in 0.5% of pregnancies, which is due to an imbalance between conjugated and unconjugated bile. Most of these resolve after birth without clinical significance, but a postnatal ultrasound is recommended, as some may be associated with hemolytic disease or other pathological findings.
Ascaris
Ascariasis is the most common helminthic parasite infection inhabiting human intestines and is endemic in India, China, and on the Africa and South American continents. , Infection occurs after ingestion of Ascaris eggs via contaminated food sources. Larvae hatch in the duodenum then enter the portal and systemic circulation by penetrating the mucosa and submucosa and migrate to the lungs, where they then enter the alveoli and migrate into the trachea. They are coughed up into the pharynx and are swallowed back into the gastrointestinal tract where they mature into worms in the small intestine. Most ascaris infections are asymptomatic; other symptoms include pneumonia, intestinal obstruction, and malnutrition. Diagnosis of hepatobiliary and pancreatic ascariasis is typically made by ultrasound, with eosinophilia present during the pulmonary stage of the disease.
Hepatobiliary and pancreatic ascariasis occurs when Ascaris lumbricoides enters the biliary tree via the duodenum, causing symptoms of biliary colic. Symptoms often resolve after 24–36 hours when the worm passes back into the duodenum, although in some cases, if the worm cannot escape but instead dies, sludge and stones can form, resulting in recurrent cholangitis. Acute pancreatitis can also occur. Albendazole is recommended in addition to the appropriate surgical intervention.
Imaging
Ultrasound
Ultrasound is the initial imaging of choice to evaluate pediatric biliary disease due to its low cost, lack of ionizing radiation, and noninvasive nature. The quality of the studies is typically adequate as children typically have a smaller body habitus and less subcutaneous fat compared to adults. Performing the ultrasound while the patient is fasting can distend the gallbladder and provide more accurate results; a recommended protocol is fasting for 3 hours for children less than 3 years of age, 6 hours for children ages 3–6 years, and 8 hours in older children.
Ultrasound findings of acute cholecystitis are typically gallstones (sometimes impacted in the gallbladder neck or cystic duct), a sonographic Murphy’s sign, gallbladder distension, wall thickening, and pericholecystic fluid. Compared with CT, ultrasound allows for the evaluation of a sonographic Murphy’s sign, which combined with the presence of gallstones, has a positive predictive value of 92% for the diagnosis of acute cholecystitis in adults. In a single-institution retrospective study, the ultrasound finding with the highest sensitivity at predicting pediatric cholecystitis was cholelithiasis (66%), while other individual findings (Murphy’s sign, pericholecystic fluid, enlarged gallbladder or sludge) had lower sensitivity, with ranges from 4% to 23%. The highest sensitivity (82%) was the presence of any one of the following factors: Murphy’s sign, gallbladder wall thickening, pericholecystic fluid, cholelithiasis, gallbladder sludge, or enlarged/distended gallbladder. While only 10% of patients had a diagnosis of cholecystitis according to the radiology report at the time, 17% had pathologic findings suggestive of acute cholecystitis and 80% had pathologic specimens concerning for chronic cholecystitis. The authors suggest earlier cholecystectomy in any child with symptoms and any gallbladder pathology on ultrasound.
Ultrasound is also the imaging of choice to assess and monitor gallbladder polyps. Doppler can assist with distinguishing a polyp from a gallstone (which usually moves with positional changes), although sometimes serial ultrasound images may be required.
Contrast-enhanced ultrasound (CEUS) is also emerging to provide more nuance in diagnosis. Intravenous 0.03 mL/kg dose of sulfur hexafluoride lipid microspheres (Lumason Bracco Diagnostics, Monroe Township, NJ) has been approved by the US Food and Drug administration for liver indications, but the same dose can be used for biliary studies. In patients with gallbladder thickening, CEUS can help elucidate the etiology. In acute cholecystitis, the gallbladder wall has transmural wall enhancement on CEUS, compared to enhancement of the inner and outer wall with hypoenhancement of the midportion of the gallbladder wall that can be seen in secondary causes of gallbladder wall thickening (such as hepatitis). CEUS can also better distinguish polyps from sludge or gallbladder wall thickening. ,
CT
CT findings suggestive of acute cholecystitis include gallstones, gallbladder distension and thickening of the gallbladder wall, pericholecystic inflammation, and subserosal edema. However, CT is not as adept at identifying gallstones as ultrasound (approximately 75% of stones are detected by CT). CT is more diagnostic in patients with acalculous cholecystitis when ultrasound or HIDA are nondiagnostic.
MRI
Magnetic resonance cholangiopancreatography (MRCP) allows evaluation of the biliary system, including a better image of the common bile duct, which may be difficult to visualize on ultrasound. This does not require intravenous contrast, but many young patients require anesthesia to complete the study. Fasting is also recommended to distend the gallbladder. The study can be further optimized by oral intake of paramagnetic substances such as ferumoxsil or pineapple or acai juice (these suppress fluid signal in the stomach and proximal small bowel) or by administering intravenous secretin (dose 0.2 μg/kg with a maximum dose of 16 μg) to enhance visualization of the pancreaticobiliary junction. Contraindications to secretin include allergy and acute pancreatitis.
HIDA
Technetium-99m (Tc-99m) labeled hepatobiliary scintigraphy can assess the biliary system’s functional status. This has a sensitivity of 98% and specificity of 70% for detecting biliary atresia but can also be used to assess gallbladder contractility. A normal study shows hepatic uptake followed by excretion into the biliary tree and small bowel within 1 hour. Delayed imaging up to 24 hours can be performed for further assessment.
An ejection fraction <35% after administration of cholecystokinin is associated with biliary hypokinesia, while an ejection fraction of >80% refers to biliary hyperkinesia. However, there is ongoing debate as to the reliability of scintigraphy in predicting gallbladder dysfunction. , ,
Surgical Interventions
Indications
Gallbladder removal may be considered in cases of symptomatic cholelithiasis or acute cholecystitis, and in patients who have suffered a complication of gallstone disease, such as choledocholithiasis or gallstone pancreatitis. Cholecystectomy is also considered in patients with biliary dyskinesia. The gallbladder of patients with biliary dyskinesia is usually grossly normal but is frequently found to have evidence of chronic cholecystitis on hematoxylin and eosin staining. Pain improvement after cholecystectomy for biliary dyskinesia hovers at about 60%. One might additionally offer preventive cholecystectomy, such as in patients with hemolytic disease undergoing splenectomy or those with morbid obesity undergoing weight reduction surgery.
Timing of operation is variable. In patients with symptomatic cholelithiasis, dietary modifications may decrease the frequency and severity of colic episodes and allow deferral or wholesale avoidance of cholecystectomy; however, adult studies examining the sequelae of index symptomatic cholelithiasis presentation in the outpatient or ED setting have not been replicated in the pediatric population. It does appear that even a single episode of severe biliary colic during childhood is predictive of eventual cholecystectomy. In the setting of acute cholecystitis and gallstone pancreatitis, robust adult data advocating early cholecystectomy, even in the face of incompletely resolved inflammation, have been reproduced in the pediatric literature and widely adopted in children’s hospitals. ,
Choledocholithiasis is addressed variably, with wide interhospital variation on timing and approach to relief of common bile duct (CBD) obstruction. Treatments include (a) primary cholecystectomy with intraoperative cholangiography and intraoperative attempts at bile duct clearance using flushing and/or common bile duct exploration; (b) preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy; or (c) a hybrid approach allowing for immediate ERCP should CBD obstruction remain unrelieved during laparoscopy. Several groups have developed grading criteria to help streamline decision making in the surgical treatment of CBD obstruction.
Gallbladder volvulus and isolated gallbladder trauma are other cases that may require cholecystectomy, although as previously discussed, are quite rare in the pediatric population.
Surgical Approach
Surgical approaches to gallbladder removal include open surgery (rarely practiced in the United States at this time unless performed during laparotomy for another indication); laparoscopy (most common); or robotic (increasingly practiced, in part to provide a learning platform for more advanced robotic surgery). Several authors have promoted the use of single-site minimally invasive surgery using a 15–20 mm umbilical multiport access device and specialized instruments. , Outcomes including costs, operative times, cosmetics, and patient satisfaction are equivalent, and a “best approach” recommendation remains that with which the surgeon is most comfortable. ,
Common to all surgical approaches is the tenet of developing a “critical view” where the surgeon dissects the lower third of the gallbladder free from the gallbladder fossa and demonstrates two tubular structures leaving the gallbladder (the cystic duct and cystic artery) prior to dividing either ( Fig. 43.1 ). In pediatric patients the cystic artery is often diminutive, and one might modify this approach by dividing small cystic artery branches as they join the gallbladder, leaving a single cystic duct connected to the gallbladder. It is prudent to visualize the liver behind and separate from the lower gallbladder dissection to avoid erroneously transecting an accessory bile duct or variant branch of the hepatic artery.
Critical view of safety, demonstrating appearance of single tubular structure exiting gallbladder neck ( white asterisk ).
Cholangiography
Several adjuncts to intraoperative visualization of the biliary tree are available, principally including radioopaque dye injected directly into the cystic duct (intraoperative cholangiography, IOC) or intravenous injection of indocyanine green (ICG), which is excreted by the liver into the biliary tree ( Fig. 43.2 ). The former requires the use of fluoroscopy while the latter requires dedicated equipment that can provide near-infrared light emission. Although appealing in theory as a method to identify anatomy, neither form of cholangiography has been shown to reduce the incidence of CBD injury, which rests at about 0.5%. ,
Critical view of safety with ICG injection, demonstrating lack of aberrant anatomy.
Cholangiography’s utility may rest in proving CBD patency in cases of choledocholithiasis or in clarifying aberrant anatomy. In addition to cholangiography, adult studies have demonstrated the utility of minimally invasive ultrasonography of the biliary tree, but this application is rarely used in pediatric patients.
Complications
Complications of cholecystectomy include those common to any intraabdominal operation (open or minimally invasive). Specific to the gallbladder, a patient may experience injury to or inadvertent ligation of the CBD, bile leak from the ligated cystic duct, bleeding from the main cystic artery stump or a branch, and bile leak or bleeding from the gallbladder fossa, either due to division of an aberrant branch of the biliary tree or hepatic artery. In addition, complications of gallstones themselves, including retained CBD or pancreatic duct stones, can occur.
Common bile duct injury is reported in approximately 0.5% of pediatric patients. Risk factors for CBD injury include surgeon volume and aberrant anatomy, but data are far less robust in pediatric series than in adults. Routine cholangiography has not been shown to decrease the rate of CBD in children. Treatment of complications after cholecystectomy is similar in adults and children, with options including percutaneous drainage of a biloma, ERCP and nasobiliary stent placement for bile leaks, and reexploration for hemorrhage.
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