Management of gallstone disease in children: a new
protocol based on the experience of a single center
Ana Cristina A. Tannuri, Antonio José Gonçalves Leal, Manoel Carlos Prieto Velhote,
Manoel Ernesto Peçanha Gonlçalves, Uenis Tannuri⁎
Pediatric Surgery Division, Pediatric Liver Transplantation Unit, Laboratory of Research in Pediatric Surgery (LIM 30),
University of Sao Paulo Medical School, Sao Paulo, Brazil
Received 25 February 2012; revised 16 June 2012; accepted 19 June 2012
Background/purpose: 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
⁎Corresponding author. Faculdade de Medicina da Universidade de São Paulo, Avenida Dr Arnaldo 455, 4oandar sala 4109, São Paulo – SP,
CEP: 01246–903, Brazil. Tel.: +55 11 30812943; fax: +55 11 32556285.
E-mail address: firstname.lastname@example.org (U. Tannuri).
0022-3468/$ – see front matter. Published by Elsevier Inc.
Journal of Pediatric Surgery (2012) 47, 2033–2038
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.
Published by Elsevier Inc.
Although gallstones have traditionally been considered to
be much less common in children than in adults, gallstone
disease has increasingly been diagnosed in the pediatric
population, mainly owing to the widespread use of
In the past, gallbladder disease in children was usually
observed primarily in patients with comorbid conditions
such as hemolytic disorders, parenteral nutrition dependence,
or cystic fibrosis [2,3]. However, the cholecystectomy rate in
children without the diagnosis of hemolytic anemia has
doubled in United States in recent years . Obesity is a
known risk factor for gallbladder disease, and the increase in
the incidence of pediatric gallbladder disease parallels the
rise in childhood obesity .
The history of gallstones in adults has shown that the
majority (N80.0%) are incidentally detected as asymptomatic
gallstones, and indeed, the majority (N80.0%) remain
asymptomatic on long-term follow-up. However, if adult
patients develop complications (eg, pancreatitis, acute
cholecystitis, or choledocolithiasis), these complications
are usually preceded by biliary colic pain . In the pediatric
population, the picture is not so clear; hence, the treatment
Another point of discussion is that, in the past, routine
intraoperative cholangiography (IOC) was recommended
during a cholecystectomy because a common bile duct
(CBD) exploration was indicated. This situation, however, is
different inthe era of laparoscopic cholecystectomy (LC) and
even more because of pediatric endoscopic retrograde
cholangiopancreatography (ERCP). Laparoscopic IOC and
CBD exploration, although feasible, are not easy to perform,
require expertise, and may be time consuming [7-9].
Furthermore, this procedure may lead to the conversion of
an LC into an open and unnecessary CBD exploration,
considering the 20.0% to 25.0% false-positive rate of IOC
 and the possibility of a stone migrating spontaneously
through the papilla and into the duodenum.
The objective of this study was to describe our experience
with the management of gallstone disease of childhood over
the last 18 years, with particular attention given to the
associated comorbidities, clinical presentation, postoperative
outcomes, surgical techniques, and our experience with IOC.
In addition, we propose an algorithm to guide the approach
to cholelithiasis in children based on clinical and ultrasono-
1. Patients and 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 at the Pediatric Surgery
Division of the Child Institute of the University of Sao Paulo
School of Medicine. This retrospective study protocol was
approved by the ethical committee of the institution.
Normal CBD in
CBD stones by
3 and 4
The algorithm utilized for patient treatment.
2034 A.C.A. Tannuri et al.
The information collected for each patient included age,
sex, associated diseases, presenting symptoms, and symptom
duration. Based on the symptoms, we divided the patients
into the following 5 groups:
Group 1: asymptomatic;
Group 2: nonbiliary obstructive symptoms (eg, recurrent pain,
abdominal discomfort, nausea related to fatty meals);
Group 3: acute cholecystitis symptoms (eg, fever, vomiting,
leukocytosis, acute right upper quadrant pain);
Group 4: a history of biliary obstructive symptoms that were
completely resolved at the time of surgery;
Group 5: ongoing biliary obstructive symptoms (eg, jaundice,
acholia, choluria, acute pancreatitis).
Ultrasonographic data included number of gallstones and
presence or absence of choledocolithiasis. Based on their
clinical, ultrasonographic, and ERCP data, patients were
treated following the algorithm in Fig. 1.
The technique used for LC was similar to that described in
12 mm Hg. A Harmonic Scalpel (Ethicon, Cincinnati, OH) or
an electrocautery hook was used for dissection. One technical
detail of note is that all of the dissections were performed very
the CBD or to the hepatic artery.
We also analyzed the following additional variables:
whether the patients had ERCP done before or after surgery;
the findings and results of the ERCP; the type of surgery
performed, LC vs open cholecystectomy (OC); whether IOC,
open CBD stone extraction, and/or Roux-en-Y hepaticojeju-
nostomy (RYH) was performed; the duration of surgery; the
need for conversion to laparotomy; major complications; and
the length of the postoperative stay. The follow-up of the
patients ranged from 3 to 122 months (median, 17 months).
During the studied period, 223 patients were diagnosed
with cholelithiasis at our institution (approximately 12
patients per year). Of these patients, 119 were female, and
the median age was 11 years (range, 2-17 years).
Comorbidities were present in 177 patients (79.3%); the
most common are listed in Table 1.
A cholecystectomy was done for all patients with
cholelithiasis, even if they were asymptomatic. Symptoms
were present in 134 patients (60.0% of all patients), as
detailed in Table 2. Symptoms were present in 61 patients
with hemolytic disorders (63.3% of them) and in 5 patients
withprevious bariatric surgery (31.2% of them). A total of 56
patients (25.1% of all patients) presented with complications
as the first sign of cholelithiasis, including pancreatitis in 28,
choledocolithiasis in 12, and acute calculous cholecystitis
(ACC) in 16. Multiple gallstones were observed in 146
patients (64.4% of all patients), and 83 (37.2% of all patients)
had 1 or 2 calculi in the gallbladder.
An LC was performed in 204 patients, OC was performed
in 17 patients, and 2 patients underwent RYH. The reasons
for initial OC indication are shown in Table 3. One 16-year-
old adolescent girl had Mirizzi syndrome, which is
characterized by extrinsic compression of the common
hepatic duct by stones impacted in the cystic duct or the
Regarding LC, the average duration of the procedure was
80.8 minutes (range, 40-240 minutes), and the average
hospital stay was 1.1 days (range, 1-3 days). A conversion to
an OC was necessary in 4 cases (1.9% of LC patients), 2 of
which were cases of ACC and 2 of which were patients with
portal hypertension. All 4 conversions occurred near the
beginning of our experience in the 1990s. An IOC was
performed in 15 cases where there was suspicion for
choledocolithiasis and yielded positive results in only 1
patient (0.4% of all patients). The child underwent ERCP to
extract the stone after LC.
Preoperative ERCP was performed on 11 patients, and
stone extraction was possible in 9 cases. The remaining 2
cases had a dilated CBD with stones. At the time of the
laparotomy, a hepaticojejunostomy was performed when
CBD stones extraction was not successful. Because of the
Comorbidities observed in the patients
ComorbidityNo. of patients (%)
History of bariatric surgery
Others (portal hypertension and
cardiac and pulmonary disorders)
Symptoms and associated conditions presented by
Symptoms No. of patients (%)
indication for an OC
Associated conditions constituting the initial
Indications for OC No. of patients
Others (asthma, previous gastroschisis,
2035Management of gallstone disease in children
complexity of these cases, other procedures, such as
laparoscopic CBD exploration or even open transduodenal
sphincteroplasty for duct clearance, were not considered.
Major postoperative complications were observed in 2
patients. Despite preoperative and intraoperative care, 1 girl
with sickle cell disease developed acute thoracic syndrome
on the first postoperative day. Clinical management with
hydratation, blood transfusion, and antibiotics resolved this
condition. The other major complication involved another
girl with sickle cell disease who developed hemoperitoneum
secondary to bleeding at a trocar site, and a laparotomy was
required to resolve this condition. There were no injuries to
the hepatic artery or to the CBD in our series.
Regarding the patients who underwent an OC or RYH,
the mean lengths of hospital stay were 3.2 days (range, 1-4
days) and 18 days (range, 6-30 days), respectively, and there
were no complications. During the follow-up, we did not
detect symptoms that could be attributable to postcholecys-
tectomy pain or any other morbidity related to the operation.
Gallstones are increasingly found in childhood, not only
because of the use of ultrasonography in the workup of
abdominal pain but also because of the increase of incidence
in obesity worldwide and the high frequency of hemolytic
anemias in all countries [1-5].
In addition to hemolytic anemias, a history of bariatric
some authors recommend concurrent prophylactic cholecys-
tectomy during laparoscopic Roux-en-Y gastric bypass in
adults, considering the low morbidity associated with
cholecystectomy andthehighindexofulterior biliarydisease
. We believe that concurrent prophylactic cholecystecto-
my may also be considered in the adolescent population.
No well-established consensus exists regarding the
indications for cholecystectomy in asymptomatic pediatric
patients . Some authors believe that it is indicated only in
patients with comorbidities, particularly hemolytic anemias
. In the present series, we observed that significant
proportion of all patients (25.1%) developed complications
related to the presence of gallstones (eg, ACC, pancreatitis,
choledocolithiasis), and the complication was the first sign
of cholelithiasis. Herzog and Bouchard  described a very
high incidence of complications (58.0%), such as pancrea-
titis, cholestasis, and choledocholithiasis in patients with
idiopathic gallstone disease. In another publication, 10 of 14
initially asymptomatic patients with sickle cell disease
became symptomatic and required surgery. In addition, the
operative time, morbidity rate, and postoperative stay were
greater among symptomatic patients who underwent chole-
cystectomy than in those who underwent the surgery when
asymptomatic . Another argument is that the presence of
gallstones is a major risk factor for carcinoma of the
gallbladder . Finally, we may consider the psychologic
consequences for the child, who will live for more than 90
additional years, and for the family when a surgical disease
However, we must consider the potential morbidity of
“unnecessary” cholecystectomies performed on asymptom-
atic patients (some cholecystectomies can also be performed
if the patient will need a laparotomy for other causes—eg,
splenectomy in hemolytic disorders and surgery for morbid
obesity). In fact, this argument should be considered before
an LC is indicated for an asymptomatic patient. Besides, it is
not known the long-term course of all children with
asymptomatic cholelithiasis, although in adult patients with
silent gallstones, it was shown no long-term risk of
symptoms or adverse events leading to cholecystectomy
. Although we had no complications in our series of
pediatric patients, a prospective follow-up study of a large
population of asymptomatic patients would be necessary to
answer this question.
The other interesting finding in our series was the high
incidence of comorbidities (79.3%). We believe that acute
complications such as pancreatitis and cholecystitis could be
life threatening in these patients. In addition, the first clinical
presentation of gallstone disease in 25.1% of patients
included some of these complications. Finally, we may
argue that, in both cases in which an RYH was necessary, the
decision to perform an LC or OC earlier in the disease course
would avoid this more extensive and morbid surgery.
Careful clinical and anesthetic preoperative evaluation is
crucial for detecting conditions that could be dangerous to a
laparoscopic approach. In such cases, we believe that open
surgery is the best approach; there were no complications
after laparotomy in our series (16 cases; 7.3% of patients)
and no drawbacks other than a larger scar. Furthermore, the
judicious use of the laparoscopic approach combined with
adequate anesthetic techniques and laparoscopic skills was
responsible for the low conversion (4 cases; 1.9 % of LC
patients) and complication rates in our series.
Another important point of discussion refers to the lessons
learned by the surgeons, which were derived from previous
surgical interventions in the liver or in the biliary tract,
primarily liver transplantation, from deceased or living
donors, or hepatic tumor resections [15,16]. Our group's
significant experience with these procedures gave us
appreciable skill in completing an LC quickly (in a little
more than 1 hour) and with a low conversion rate to an OC
(1.9 %). Finally, thanks to our technique of performing the
dissections quite close to the gallbladder, we caused no
injuries to the CBD or to the hepatic artery.
Routine IOC, even in suspected cases of choledocolithia-
sis, is often associated with negative results , and we
identified only 1 positive case among the 15 patients studied.
Although we believe that IOC may also be indicated for a
better definition of the biliary anatomy and that it is a useful
tool in liver and biliary tract surgeries, it is not necessary
during an LC because all of the dissection procedures are
performed very close to the gallbladder. In addition,
2036A.C.A. Tannuri et al.
preoperative ultrasound examinations permit the precise
evaluation of the biliary tract anatomy.
Endoscopic retrograde cholangiopancreatography can be
safely and effectively performed in suspected children by
experienced endoscopists, during both the postoperative and
preoperative periods . Laparoscopic exploration of the
CBD is feasible, but it is a procedure that requires training
and equipment not usually available in all institutions.
Moreover, unlike what is observed in adults, CBD stones in
children usually pass spontaneously without any significant
complication [8,9]. When ERCP failed to remove the stones,
even surgery with opening of the CBD was not successful
and RYH was required.
Based on our experience, we can propose a new algorithm
to guide the approach to cholelithiasis in children (Fig. 2).
The final conclusion is that cholecystectomy should be
performed laparoscopically in pediatric patients with gall-
stones. This procedure has low rates of postoperative
complications. In children, when a previous diagnosis of
choledocolithiasis or choledochus dilation has been made,
ERCP is necessary if obstructive symptoms persist, either
before or after an LC. Intraoperative cholangiography and
laparoscopic CBD exploration, although feasible, are not
mandatory. An RYH or an open sphincteroplasty may be
required when the stones present in dilated CBD cannot be
extracted by ERCP. Finally, other studies using large multi-
institutional databases will be able to definitely answer and
confirm our conclusions.
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