title: Management of gallstone disease in children: a new protocol based on the experience of a single center.
abstract: OBJECTIVE
  Gallstones and cholelithiasis are being increasingly diagnosed in children owing to the widespread use of ultrasonography. The treatment of choice is cholecystectomy, and routine intraoperative cholangiography is recommended to explore the common bile duct. The objectives of this study were to describe our experience with the management of gallstone disease in childhood over the last 18 years and to propose an algorithm to guide the approach to cholelithiasis in children based on clinical and ultrasonographic findings.
  
  
  METHODS
  The data for this study were obtained by reviewing the records of all patients with gallstone disease treated between January 1994 and October 2011. The patients were divided into the following 5 groups based on their symptoms: group 1, asymptomatic; group 2, nonbiliary obstructive symptoms; group 3, acute cholecystitis symptoms; group 4, a history of biliary obstructive symptoms that were completely resolved by the time of surgery; and group 5, ongoing biliary obstructive symptoms. Patients were treated according to an algorithm based on their clinical, ultrasonographic, and endoscopic retrograde cholangiopancreatography (ERCP) findings.
  
  
  RESULTS
  A total of 223 patients were diagnosed with cholelithiasis, and comorbidities were present in 177 patients (79.3%). The most common comorbidities were hemolytic disorders in 139 patients (62.3%) and previous bariatric surgery in 16 (7.1%). Although symptoms were present in 134 patients (60.0%), cholecystectomy was performed for all patients with cholelithiasis, even if they were asymptomatic; the surgery was laparoscopic in 204 patients and open in 19. Fifty-six patients (25.1%) presented with complications as the first sign of cholelithiasis (eg, pancreatitis, choledocolithiasis, or acute calculous cholecystitis). Intraoperative cholangiography was indicated in 15 children, and it was positive in only 1 (0.4%) for whom ERCP was necessary to extract the stone after a laparoscopic cholecystectomy (LC). Preoperative ERCP was performed in 11 patients to extract the stones, and a hepaticojejunostomy was indicated in 2 patients. There were no injuries to the hepatic artery or common bile duct in our series.
  
  
  CONCLUSIONS
  Based on our experience, we can propose an algorithm to guide the approach to cholelithiasis in the pediatric population. The final conclusion is that LC results in limited postoperative complications in children with gallstones. When a diagnosis of choledocolithiasis or dilation of the choledocus is made, ERCP is necessary if obstructive symptoms persist either before or after an LC. Intraoperative cholangiography and laparoscopic common bile duct exploration are not mandatory.
authors.affiliation: Pediatric Surgery Division, Pediatric Liver Transplantation Unit, Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Ana Cristina A
authors.initials: AC
authors.lastname: Tannuri
authors.forename: Antonio José Gonçalves
authors.initials: AJ
authors.lastname: Leal
authors.forename: Manoel Carlos Prieto
authors.initials: MC
authors.lastname: Velhote
authors.forename: Manoel Ernesto Peçanha
authors.initials: ME
authors.lastname: Gonlçalves
authors.forename: Uenis
authors.initials: U
authors.lastname: Tannuri
mesh_terms: D000293:Adolescent; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002763:Cholecystectomy / Q000379:methods; D017081:Cholecystectomy, Laparoscopic; D041881:Cholecystitis, Acute / Q000209:etiology; D002769:Cholelithiasis / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D002985:Clinical Protocols; D015897:Comorbidity; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome