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Akinsanya A, González IA. Evaluating Intestinal Metaplasia in Pediatric Gallbladder Specimens: Clinicopathologic Significance and Sampling Thresholds. Pediatr Dev Pathol 2025:10935266251341508. [PMID: 40391422 DOI: 10.1177/10935266251341508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2025]
Abstract
BACKGROUND Gallbladders are a commonly encounter specimen in pediatric pathology practice. In the adult population, intestinal metaplasia (IM) in the gallbladder is associated with the development of dysplasia and adenocarcinoma; however, in children its significance is unknown, and the appropriate sampling has not been described which is the goal of this study. METHODS Twenty-five routine pediatric cholecystectomy cases with IM were identified, and their clinical and histologic findings were reviewed. RESULTS Of these 25 cases, 23 were female (92%). The most common indication for surgery was cholelithiasis (84%). Stones were present in 21 cases (84%). Twenty-three cases (92%) had additional sections submitted with an average of 3.9 slides (range = 3-6), and 52% had IM in additional blocks. However, no dysplasia or carcinoma was identified in any case. CONCLUSION IM in the gallbladder is frequently seen in the setting of gallstones and chronic inflammation. Based on our experience, no additional sampling is required when incidentally identified.
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Affiliation(s)
- Adeyinka Akinsanya
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Iván A González
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Thrower AI, Roberts A, Lee JP, Chumpitazi BP. Primary choledocholithiasis after cholecystectomy without hyperbilirubinaemia in a child with sickle cell disease. BMJ Case Rep 2025; 18:e261650. [PMID: 40240138 DOI: 10.1136/bcr-2024-261650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2025] Open
Abstract
Children with sickle cell disease (SCD) may have hepatobiliary pathology secondary to chronic haemolysis and intrahepatic sickling during vaso-occlusive crisis. Choledocholithiasis in children with SCD is usually secondary to cholelithiasis but, less commonly, can be due to primary choledocholithiasis. A known history of cholecystectomy may lead to a delay in diagnosis of biliary tract pathology in sickle cell patients presenting with abdominal pain. Normal conjugated bilirubin levels may further stray healthcare providers away from considering biliary disease in these patients. Here, we report an unusual case of primary choledocholithiasis in a child with SCD after cholecystectomy with normal conjugated bilirubin at the time of presentation.
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Affiliation(s)
- Ashley Inez Thrower
- Internal Medicine and Pediatrics, Duke University, Durham, North Carolina, USA
| | - Annette Roberts
- Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Joshua P Lee
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Rodhouse C, Raymond R, Neal D, Loftus TJ, Khan FA, Do AR, Taylor JA, Efron PA, Larson SD, Raymond SL. Antibiotic Prophylaxis for Elective Pediatric Laparoscopic Cholecystectomies. J Pediatr Surg 2025; 60:162055. [PMID: 39549681 DOI: 10.1016/j.jpedsurg.2024.162055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/19/2024] [Accepted: 10/30/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND The Surgical Infection Society (SIS) guidelines recommend against the use of surgical antibiotic prophylaxis (SAP) for low-risk patients undergoing elective laparoscopic cholecystectomies. METHODS Using National Surgical Quality Improvement Program (NSQIP) data, 5440 pediatric patients were identified who underwent laparoscopic cholecystectomy from 2021 to 2022. Patients who had immunodeficiency, active malignancy, American Society of Anesthesiologists (ASA) physical status classification 3-5, procedure indicated for infection, emergent procedure, received intravenous antibiotics before the prophylaxis window, or missing SAP data were excluded. RESULTS 3959 patients were included in the analysis. Among these patients, 3570 (90.2 %) received SAP. Overall incidence of 30-day superficial incisional surgical site infection (SSI), deep incisional SSI, and organ space SSI were 0.9 %, 0.0 %, and 0.1 %, respectively. The incidence of superficial incisional SSI was significantly higher in the patients who did not receive SAP (SAP 0.8 %, no SAP 2.1 %; p = 0.024). The incidence of organ space SSI was also significantly higher in the patients who did not receive SAP (SAP 0.1 %, no SAP 0.8 %; p = 0.008). There was no difference in the incidence of C. diff colitis (SAP 0.1 %, no SAP 0.0 %; p = 1.000). Multivariable modeling, controlling for Hispanic ethnicity, age, and gender, demonstrated patients that received SAP were significantly less likely to have any postoperative SSI compared to patients who did not receive SAP (OR = 0.35). CONCLUSION Hospitals are not currently compliant with SIS guidelines regarding omission of antibiotic prophylaxis for low-risk patients undergoing elective laparoscopic cholecystectomies. The authors advocate for additional studies and reassessment of current guidelines for pediatric patients given the above findings. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Dan Neal
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Faraz A Khan
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Ana R Do
- Division of Pediatric Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Janice A Taylor
- Division of Pediatric Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Shawn D Larson
- Division of Pediatric Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Steven L Raymond
- Division of Pediatric Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA.
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Keane OA, Ourshalimian S, Ignacio R, Acker S, Jensen A, Lofberg K, Mueller C, Padilla BE, Pandya S, Rothstein DH, Russell KW, Smith C, O'Guinn M, Ing M, Floan Sachs G, Highet A, Iantorno SE, Templeton LR, Ochoa B, Patwardhan UM, Peace A, Schwab ME, Tran TH, Kelley-Quon LI. Pediatric Cholecystectomy Case Volume and Complexity Following the COVID-19 Pandemic. Pediatrics 2025:e2024068065. [PMID: 39978405 DOI: 10.1542/peds.2024-068065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 11/13/2024] [Indexed: 02/22/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic. METHODS A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children's hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis. RESULTS Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0-16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients. CONCLUSIONS Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children's hospitals.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | | | - Romeo Ignacio
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California
| | - Shannon Acker
- Department of Surgery, Children's Hospital Colorado, University of Colorado, Aurora, California
| | - Aaron Jensen
- Department of Surgery, University of California San Francisco School of Medicine, and UCSF Benioff Children's Hospitals, San Francisco, California
| | - Katrine Lofberg
- Department of Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Claudia Mueller
- cbaStanford Medicine Children's Health, Palo Alto, California
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Pheonix, Arizona
| | - Samir Pandya
- Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David H Rothstein
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
| | - Katie W Russell
- Division of Pediatric Surgery, Phoenix Children's Hospital, Pheonix, Arizona
| | - Caitlin Smith
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
| | - MaKayla O'Guinn
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Madeleine Ing
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Gretchen Floan Sachs
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California
| | - Alexandra Highet
- Department of Surgery, University of California San Francisco School of Medicine, and UCSF Benioff Children's Hospitals, San Francisco, California
| | | | - Lauren R Templeton
- Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brielle Ochoa
- Division of Pediatric Surgery, Phoenix Children's Hospital, Pheonix, Arizona
| | - Utsav M Patwardhan
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California
| | - Alyssa Peace
- Department of Surgery, Children's Hospital Colorado, University of Colorado, Aurora, California
| | - Marisa E Schwab
- cbaStanford Medicine Children's Health, Palo Alto, California
| | - Tina H Tran
- Department of Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Lorraine I Kelley-Quon
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
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Sinha A, Mattson A, Njere I, Sinha CK. Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis. Ann R Coll Surg Engl 2025; 107:98-105. [PMID: 38445605 PMCID: PMC11785448 DOI: 10.1308/rcsann.2023.0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs). METHODS A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US). RESULTS A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92). CONCLUSIONS The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.
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Affiliation(s)
- A Sinha
- East and North Hertfordshire NHS Trust, UK
| | - A Mattson
- St George’s University Hospitals NHS Foundation Trust, UK
| | - I Njere
- Royal Devon University Healthcare NHS Foundation Trust, UK
| | - CK Sinha
- St George’s University Hospitals NHS Foundation Trust, UK
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Lucocq J, Joseph N, Knoph CS, Abu-El-Haija M, Scheers I, Drewes AM, Pandanaboyana S. Analgesia in paediatric acute pancreatitis: A scoping systematic review. J Pediatr Gastroenterol Nutr 2025; 80:203-208. [PMID: 39563649 DOI: 10.1002/jpn3.12418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/28/2024] [Accepted: 09/08/2024] [Indexed: 11/21/2024]
Abstract
OBJECTIVE Acute pancreatitis (AP) is a common paediatric condition, yet there is little data to support optimal analgesic practice. The aim of this scoping review was to report analgesic practice, investigate trends in analgesic strategy and evaluate the impact of analgesic modality on outcomes. METHODS A systematic search of Medline, Embase, CENTRAL, Pubmed Central and Google Scholar was performed by two independent investigators. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. RESULTS Three retrospective cohort studies, all conducted in North America, reported on analgesic practice in paediatric AP. The studies included 658 patients (median age, 12 years; female sex, 57%; non-biliary aetiology, 85.9%). Overall, analgesia was administered in 67% of patients, including opioids in 59.5% (43.8%-71.4%). Rates of acetaminophen (17.9% and 77.7%) and non-steroidal anti-inflammatory drugs (7.7% and 40.2%) were reported in two studies. Two studies reported reducing rates of opioid administration or reduced duration of opioid administration since 2017 and 2014, respectively. One study did not find any correlation between opioid administration and sociodemographic factors, length of stay or admission to intensive care units. No studies reported on complications or quality of life. No studies investigated non-medical modalities. There were no long-term data on analgesic use post-discharge. CONCLUSIONS Opioids are the mainstay of pain treatment in paediatric AP in North America. However, factors that influence the analgesic type, the impact of analgesic modality on the post-pancreatitis outcome and long-term analgesic use constitute a knowledge gap. Future studies are needed to inform analgesic use in paediatric AP.
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Affiliation(s)
- James Lucocq
- Department of General Surgery, NHS Lothian, Edinburgh, UK
| | - Nejo Joseph
- Palmerston North Hospital, Health New Zealand, Midcentral, Palmerston North, New Zealand
| | - Cecilie Sigaard Knoph
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University, Aalborg, Denmark
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Isabelle Scheers
- Paediatric Gastroenterology and Hepatology, Centre for Rare Pancreatic Diseases, Cliniques universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Asbjorn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University, Aalborg, Denmark
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Hospitals and NHS Foundation Trust, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
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Mutua S, Sevagamoorthy A, Woidill S, Orchard PJ, Gavazzi F, MacFarland SP, Russo P, Vanderver A, Adang LA. Characterization of gallbladder disease in metachromatic leukodystrophy across the lifespan. Mol Genet Metab 2025; 144:109003. [PMID: 39733668 PMCID: PMC11781823 DOI: 10.1016/j.ymgme.2024.109003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Revised: 11/18/2024] [Accepted: 12/15/2024] [Indexed: 12/31/2024]
Abstract
Metachromatic leukodystrophy (MLD) is a progressive demyelinating disorder resulting from the toxic accumulation of sulfatides. The stereotyped neurodegeneration of MLD is well understood, and cases are categorized into subtypes by age at neurologic onset: late infantile (LI), juvenile (J), and adult. The systemic burden of disease, such as gallbladder involvement, however, is less well characterized. It is important to understand the longitudinal trajectory of gallbladder complications in MLD and its relationship with neurologic progression as this has the potential to identify cases of active disease before neurologic onset. Additionally, as newborn screening is established in MLD, it will inform clinical care during the presymptomatic period. To address this knowledge gap, we leveraged a retrospective natural history study of MLD and published cases in the medical literature. Medical records from subjects consented to a natural history study were used to collect information of disease course, including gallbladder abnormality. Neurologic function was retrospectively assessed using the gross motor function classification scale (GMFC-MLD). Additionally, a comprehensive review identified published cases of MLD with subject-level information around gallbladder disease. Data was summarized using descriptive statistics, Fisher's exact test for significance, and survival analysis with log rank test. The natural history cohort includes 40 subjects with gallbladder reports (imaging or pathology). The first gallbladder evaluation occurred after neurologic onset in 35/40 cases. Gallbladder abnormalities were noted in 36 subjects, often within the initial evaluation (97.2 %). There was no difference in the time to first gallbladder abnormality (log rank: p = 0.4170) and risk of polyps or higher (log rank: p = 0.6414) between the LI- and non-LI subtypes. The level of gallbladder involvement does not correlate with GMFC-MLD score (Fisher's exact: p = 0.321). A review of the literature identified 87 additional cases of MLD with mention of gallbladder status across 40 published studies. Gallbladder involvement was noted in 74 cases and occurred at similar rates across subtypes (X2 = 4.68, p = 0.7925). Overall, the study showed a high prevalence of gallbladder complications in MLD. Gallbladder abnormalities were commonly found at first evaluation, even in pre- or early symptomatic disease. Since gallbladder disease has the potential to progress to malignancy, this supports the integration of regular gallbladder monitoring as clinical care and its potential as a predictive biomarker supporting disease onset.
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Affiliation(s)
- Sylvia Mutua
- The Children's Hospital of Philadelphia, Neurology, 3401 Civic Center Blvd, Philadelphia 19104, PA, USA.
| | - Anjana Sevagamoorthy
- The Children's Hospital of Philadelphia, Neurology, 3401 Civic Center Blvd, Philadelphia 19104, PA, USA.
| | - Sarah Woidill
- The Children's Hospital of Philadelphia, Neurology, 3401 Civic Center Blvd, Philadelphia 19104, PA, USA.
| | - Paul J Orchard
- University of Minnesota, Pediatrics, 660B Masonic Cancer Research Center MMC 366, Minneapolis, MN 55455, USA.
| | - Francesco Gavazzi
- The Children's Hospital of Philadelphia, Neurology, 3401 Civic Center Blvd, Philadelphia 19104, PA, USA.
| | - Suzanne P MacFarland
- The Children's Hospital of Philadelphia, Oncology, 3501 Civic Center Boulevard, CTRB 3054, Philadelphia, PA 19104, USA.
| | - Pierre Russo
- The Children's Hospital of Philadelphia, Pathology, 3401 South 34th St, Main Building 5NW26, Philadelphia, PA 19104, USA.
| | - Adeline Vanderver
- The Children's Hospital of Philadelphia, Neurology, 3401 Civic Center Blvd, Philadelphia 19104, PA, USA.
| | - Laura A Adang
- The Children's Hospital of Philadelphia, Neurology, 3401 Civic Center Blvd, Philadelphia 19104, PA, USA.
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Çakar S, Eren G, Erdur CB, Önder M, Pelek Ş, Alpdoğan S, Demirtaş D, Ecevit ÇÖ, Bekem Ö. Cholelithiasis in Infants: Risk Factors, Management, and the Role of Ursodeoxycholic Acid. CHILDREN (BASEL, SWITZERLAND) 2024; 11:1553. [PMID: 39767982 PMCID: PMC11727357 DOI: 10.3390/children11121553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 12/18/2024] [Accepted: 12/19/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Cholelithiasis is a rare disease in infants, and there is limited data on its risk factors and management. OBJECTIVES To evaluate the risk factors, management, and response to medical treatment of cholelithiasis in infants. METHODS Infants diagnosed with cholelithiasis by ultrasound between 2018 and 2023 were retrospectively analyzed. Details of patient history, imaging findings, current symptoms, and treatments were reviewed. RESULTS Over 5 years, 98 infants were diagnosed with cholelithiasis. Thirty-three (33.7%) were girls, and the most common risk factors were the use of cephalosporin antibiotic therapy in 46.9%, sepsis in 30.6%, total parenteral nutrition in 29.6%, prematurity in 27.6%, congenital heart disease in 18.4%, and genetic disease (Down syndrome diagnosis in seven patients) in 16.3%. Only fifteen patients (15.3%) were symptomatic. Ursodeoxycholic acid (UDCA) treatment was given to 90.8% of patients, but nine of them used it for a short period or irregularly, and regular users were 81.6%. Gallstones disappeared in 46 patients (46.9%), including 14 (30.4%) without using UDCA regularly. The response rate to UDCA treatment was lower in preterm infants (p = 0.004). Gallstone resolution was higher in the nonusers, 14/18 (77.8%) versus 32/79 (40.5%) (p = 0.03). Acute cholecystitis was observed in only four patients; no other complications were noted. No infant required surgical or endoscopic treatment. CONCLUSIONS UDCA should not be used routinely in children, especially infants, except in symptomatic children with a contraindication to surgery or to reduce clinical symptoms. In the absence of symptoms, patients may be monitored clinically.
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Affiliation(s)
- Sevim Çakar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35330, Turkey
| | - Gülin Eren
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
| | - Cahit Barış Erdur
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
| | - Mehmet Önder
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
| | - Şafak Pelek
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
| | - Sedef Alpdoğan
- Department of Pediatrics, Faculty of Medicine, Ege University, Izmir 35040, Turkey;
| | - Duygu Demirtaş
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
| | - Çiğdem Ömür Ecevit
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
| | - Özlem Bekem
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences Dr. Behçet Uz Children’s Hospital, Izmir 35210, Turkey; (G.E.); (C.B.E.); (M.Ö.); (Ş.P.); (D.D.); (Ç.Ö.E.); (Ö.B.)
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9
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Ünlüsoy Aksu A, Genel N, Şahin G, Özbay Hoşnut F, Tok A, Karaman A. Cholecystectomy in children: indications, clinical, laboratory and histopathological findings and cost analysis. Turk J Pediatr 2024; 66:473-480. [PMID: 39387421 DOI: 10.24953/turkjpediatr.2024.4921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 08/12/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND The most common indication for cholecystectomy in children is cholelithiasis, and routine histopathological examination is performed on all gallbladder specimens. Currently, selective histopathological examination is suggested instead of routine examination due to the low frequency of gallbladder cancer in adults. The purpose of this study was to evaluate the indications, clinical, laboratory and histopathological findings of the cholecystectomy in children. We also questioned the contribution and cost-effectiveness of routine histopathological evaluation in diagnosis and treatment. METHODS A total of 114 children underwent cholecystectomy between the years 2008 and 2022. The clinical findings, laboratory, and imaging results of the patients and histopathological findings of the gallbladder specimens were evaluated retrospectively. RESULTS Cholelithiasis were diagnosed in 71%, choledochal malformation in 15.8%, hydrops of gallbladder and/or biliary sludge in 12.3%, and hypoplasia of gallbladder in 0.9% of the patients. Histopathologically significant findings were observed in only 3 patients (2.6%); adenomyomatosis in 2 and angiodysplasia and pyloric metaplasia in 1. While the cost of a cholecystectomy and histopathologic examination combined amounted to 27.77% of the minimum wage in Türkiye in 2024, the histopathologic examination alone constitutes just 0.67% of the minimum wage and 2.4% of the operation fee. CONCLUSION In children undergoing cholecystectomy, histopathological examination does not provide any significant contribution to the patient's diagnosis and follow-up management. In children, selective gallbladder histopathological examination might reduce health costs and save time for pathologists.
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Affiliation(s)
- Aysel Ünlüsoy Aksu
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Nebiyye Genel
- Department of Pathology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Gülseren Şahin
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Ferda Özbay Hoşnut
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Ayşegül Tok
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Ayşe Karaman
- Department of Pediatric Surgery, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
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10
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Fu C, Jin H, Fang L, Xu H. Laparoscope combined with ureteroscope in the treatment of bile duct stones and cholecystolithiasis in a child: a case report and literature review. Front Med (Lausanne) 2024; 11:1429127. [PMID: 39421867 PMCID: PMC11483362 DOI: 10.3389/fmed.2024.1429127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 09/12/2024] [Indexed: 10/19/2024] Open
Abstract
Cholecystolithiasis combined with bile duct stones is more and more common in children, but the surgical treatment is still controversial. We report on a 3-year-old boy, who underwent laparoscope combined with ureteroscope for choledocholithiasis with cholecystolithiasis. This combination therapy offers the possibility to treat pediatric patients with cholecystolithiasis and bile duct stones in low-resource settings where ERCP experience and child-specific surgical instruments are not available. Additionally, a comprehensive review of previous studies was conducted to summarize the surgical treatments. The surgical treatment of children should be made according to the specific situation to maximize the success of the operation and reduce the risk.
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Affiliation(s)
- Chang Fu
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Hengwei Jin
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Lijun Fang
- Department of General Surgery, Liaoyuan People’s Hospital, Liaoyuan, China
| | - Hongji Xu
- Department of Abdominal Surgery, Guiqian International General Hospital, Guiyang, China
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11
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Fornari M, Claiborne MK, Breslin K, Sanchez-Jacob R, Khan MA, Thomas-Mohtat R. Utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis in children. Am J Emerg Med 2024; 79:38-43. [PMID: 38341992 DOI: 10.1016/j.ajem.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Ultrasound is an integral part of evaluating for acute cholecystitis and choledocholithiasis in pediatric patients. Finding the common bile duct (CBD), a structure which is normally <4 mm in children, can be very challenging. OBJECTIVE The primary objective of this study was to determine the prevalence of isolated sonographic CBD dilation in pediatric patients with acute cholecystitis and/or choledocholithiasis without laboratory abnormalities or pathologic findings on radiology based biliary ultrasound, apart from cholelithiasis. METHODS We conducted a retrospective chart review of patients ≤21-years-old, at a single free-standing tertiary care children's hospital, who received a biliary ultrasound in the radiology department (RADUS) from September 2005 to February 2020. We identified patients who had a diagnosis of acute cholecystitis and/or choledocholithiasis on RADUS. Based on prior studies, a positive ultrasound was defined as having gallbladder wall thickening (GWT), pericholecystic fluid (PCF), or sonographic Murphy's sign (SMS). The final diagnosis was confirmed using the gold standard, cholecystectomy pathology diagnosis for patients with cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) diagnosis for patients with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. RESULTS 180 patients met inclusion criteria. For the study population, 97 (53.9%) had a positive ultrasound, 127 patients (70.6%) had a dilated CBD, and 170 (94.4%) had at least one abnormal laboratory finding. Within the study population there were 76 patients (42.3%) with acute cholecystitis, 55 patients (30.5%) with choledocholithiasis, and 49 patients (27.2%) with acute cholecystitis and choledocholithiasis. Of the 127 patients with a dilated CBD, 80 (62.9%) had a normal ultrasound, apart from cholelithiasis. In this group of 80, 78 patients (97.5%) had at least one abnormal laboratory finding. Thus, for the entire study population, isolated CBD dilation without a positive ultrasound or laboratory abnormalities occurred in 2 patients (1.1%). Of note, these 2 patients had an ultrasound diagnosis of choledocholithiasis. CONCLUSION The prevalence of isolated sonographic CBD dilation in pediatric patients with cholecystitis and/or choledocholithiasis was 1.1%. Thus, biliary ultrasound without CBD measurement is unlikely to result in missed cholecystitis and/or choledocholithiasis if the biliary ultrasound does not demonstrate GWT, PCF, SMS, or choledocholithiasis, and the patient has normal laboratory values.
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Affiliation(s)
- Marci Fornari
- Cooper University Health Care, Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Cooper Medical School of Rowan University, 1 Cooper Plaza, Camden, NJ 08103, USA.
| | - Mary Kate Claiborne
- Children's Hospital of Philadelphia, Department of Pediatrics, Division of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Kristen Breslin
- Children's National Hospital, Department of Pediatrics, Division of Emergency Medicine, George Washington School of University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010, USA.
| | - Ramon Sanchez-Jacob
- Children's National Hospital, Department of Pediatrics, Division of Diagnostic Imaging and Radiology, George Washington School of University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010, USA.
| | - Muhammad A Khan
- Nationwide Children's Hospital, Department of Pediatrics, Division of Gastroenterology, The Ohio State University College of Medicine, 700 Childrens Drive, Columbus, OH 43205, USA.
| | - Rosemary Thomas-Mohtat
- Children's National Hospital, Department of Pediatrics, Division of Emergency Medicine, George Washington School of University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010, USA.
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12
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Rauh J, Dantes G, Wallace M, Collings A, Sanin GD, Cambronero GE, Bosley ME, Ganapathy AS, Patterson JW, Ignacio R, Knod JL, Slater B, Callier K, Livingston MH, Alemayehu H, Dukleska K, Scholz S, Santore MT, Zamora IJ, Neff LP. Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study. J Pediatr Surg 2024; 59:389-392. [PMID: 37957103 DOI: 10.1016/j.jpedsurg.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. METHODS A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. RESULTS Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05). CONCLUSION Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jessica Rauh
- Wake Forest School of Medicine, Winston Salem, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lucas P Neff
- Wake Forest School of Medicine, Winston Salem, USA
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13
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Floan Sachs G, Ourshalimian S, Jensen AR, Kelley-Quon LI, Padilla BE, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Ignacio RC. Machine learning to predict pediatric choledocholithiasis: A Western Pediatric Surgery Research Consortium retrospective study. Surgery 2023; 174:934-939. [PMID: 37580219 DOI: 10.1016/j.surg.2023.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/24/2023] [Accepted: 07/08/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm. METHODS A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset. RESULTS A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935. CONCLUSION This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis.
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Affiliation(s)
- Gretchen Floan Sachs
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, CA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco School of Medicine, CA; Division of Pediatric Surgery, University of California San Francisco Benioff Children's Hospitals, Oakland, CA. https://twitter.com/arjensenmd
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA. https://twitter.com/LKelley_Quon
| | | | - Stephen B Shew
- Division of Pediatric Surgery, Stanford Children's Hospital, Palo Alto, CA
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR. https://twitter.com/katierussellmd
| | - Caitlin A Smith
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, WA
| | - Jonathan P Roach
- Department of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Samir R Pandya
- Department of Pediatric General and Thoracic Surgery, University of Texas Southwestern, Dallas, TX
| | - Katie W Russell
- Division of General Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | - Romeo C Ignacio
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, CA.
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14
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Todesco C, Molinaro F, Nascimben F, Gentilucci G, Messina M, Cortese A, Briganti V, Tursini S. Gallbladder Stones in Pediatric Age: An Emerging Problem: The Risk of Difficult Cholecystectomy and the Importance of a Preoperative Evaluation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1544. [PMID: 37761505 PMCID: PMC10529449 DOI: 10.3390/children10091544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
The need for cholecystectomy during pediatric age has significantly increased in the last two decades. As biliary pathology increases, the probability of complicated cholecystectomies increases too. The aim of this article is to analyze our experience with difficult laparoscopic pediatric cholecystectomy, focusing on the importance of an accurate pre-operative imaging study. We retrospectively analyzed all patients affected by cholelithiasis who underwent laparoscopic cholecystectomy at the Pediatric Surgery Department of San Camillo Forlanini hospital of Rome and Santa Maria alle Scotte University Hospital of Siena from 2017 to 2022. Demographic data, body mass index (BMI), recovery data, laboratory tests, imaging exams, surgical findings, post operative management and outcome were taken into account. Overall, 34 pediatric patients, with a mean age of 14.1 years (6-18 years) were included, with a mean BMI of 29. All patients underwent abdominal ultrasonography and a liver MRI with cholangiography (cMRI). We identified five cases as "difficult cholecystectomies". Two subtotal cholecystectomies were performed. Cholecystectomy in pediatric surgery can be difficult. The surgeon must be able to find alternative strategies to total cholecystectomy to avoid the risk of possible bile duct injury (BDI). Pre-operative imaging study trough ultrasound and especially cMRI is crucial to recognize possible difficulties and to plan the surgery.
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Affiliation(s)
- Camilla Todesco
- Operative Unit of Pediatric Surgery—Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy (V.B.)
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, Policlinico Le Scotte, University of Siena, 53100 Siena, Italy; (F.M.); (F.N.); (M.M.)
| | - Francesco Molinaro
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, Policlinico Le Scotte, University of Siena, 53100 Siena, Italy; (F.M.); (F.N.); (M.M.)
| | - Francesca Nascimben
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, Policlinico Le Scotte, University of Siena, 53100 Siena, Italy; (F.M.); (F.N.); (M.M.)
| | - Gianluca Gentilucci
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, Policlinico Le Scotte, University of Siena, 53100 Siena, Italy; (F.M.); (F.N.); (M.M.)
| | - Mario Messina
- Department of Medical Sciences, Surgery and Neuroscience, Section of Pediatric Surgery, Policlinico Le Scotte, University of Siena, 53100 Siena, Italy; (F.M.); (F.N.); (M.M.)
| | - Andrea Cortese
- Operative Unit of Radiology and Diagnostic Imaging—Azienda Ospedaliera San Camillo Forlanini, 00152 Roma, Italy
| | - Vito Briganti
- Operative Unit of Pediatric Surgery—Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy (V.B.)
| | - Stefano Tursini
- Operative Unit of Pediatric Surgery—Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy (V.B.)
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15
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Baddam A, Akuma O, Raj R, Akuma CM, Augustine SW, Sheikh Hanafi I, Singh G, Zain A, Azizz N, Singh M, Makheja K, Rahul F, Khan A. Analysis of Risk Factors for Cholelithiasis: A Single-Center Retrospective Study. Cureus 2023; 15:e46155. [PMID: 37900464 PMCID: PMC10613112 DOI: 10.7759/cureus.46155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives Cholelithiasis poses a considerable medical burden worldwide. While its pathogenesis is multifactorial, identifying the key risk factors is essential for understanding the disease and improving patient care. This study aims to investigate the potential associations between demographic, clinical, and laboratory variables and the development of cholelithiasis. Methods This single-center retrospective study was conducted at Malla Reddy Institute of Medical Sciences, Hyderabad, India, over one month. A total of 200 patients diagnosed with cholelithiasis were included. Data were extracted from electronic health records and the patients using a questionnaire, including demographic information (age, gender), clinical data including body mass index (BMI), and comorbidities. Statistical analyses were conducted to determine the associations between risk factors and cholelithiasis. Results The frequency of cholelithiasis is found to be higher in the female gender and patients with obesity, sedentary lifestyle and hypertension as compared to male patients, and the risk of cholelithiasis also increases with age. Females demonstrated a higher prevalence of cholelithiasis, with an odds ratio (OR) and confidence interval (CI) of 1.4, 95% CI [1.1, 1.7], p < 0.05). Obese individuals (BMI ≥ 30) had 2.2 times higher odds of cholelithiasis compared to those with normal BMI (< 24.9) (OR = 2.2, 95% CI [1.7, 2.9], p < 0.001). The presence of diabetes significantly increased the odds of cholelithiasis by 1.6 times (OR = 1.6, 95% CI [1.2, 2.1], p < 0.01). Overweight individuals (BMI: 25-29.9) were associated with 1.4 times higher odds of cholelithiasis (OR = 1.4, 95% CI [1.1, 1.9], p < 0.05). Conclusion Our study identified age, gender, BMI, diabetes, and obesity as significant risk factors for cholelithiasis. These findings underscore the importance of targeted interventions and lifestyle modifications to mitigate cholelithiasis risk and improve patient outcomes. Further research, including prospective multicentric studies, must validate these findings and explore potential underlying mechanisms.
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Affiliation(s)
- Anusha Baddam
- Medicine and Surgery, Malla Reddy Medical College for Women, Hyderabad, IND
| | | | - Rohan Raj
- Internal Medicine, Nalanda Medical College and Hospital, Patna, IND
| | - Chinaza M Akuma
- Medicine, College of Health Professions, Chamberlain University, Chicago, USA
| | - Sana W Augustine
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | | | | | - Ahmer Zain
- General Medicine, Kempegowda Institute of Medical Sciences, Bangalore, IND
| | - Nasihudeen Azizz
- Internal Medicine, Kempegowda Institute of Medical Sciences, Bangalore, IND
| | - Manjeet Singh
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Kainat Makheja
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Fnu Rahul
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Aadil Khan
- Trauma Surgery, OSF St. Francis Medical Centre, Peoria, USA
- Cardiology, University of Illinois at Chicago, Chicago, USA
- Internal Medicine, Lala Lajpat Rai (LLR) Hospital, Kanpur, IND
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16
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Hey MT, Mayhew M, Rico S, Calisto J, Shaffiey S, Malvezzi L, Alkhoury F. Pediatric Single-Incision Robotic Cholecystectomy: A 6-Year Update from a Single Institution. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37311163 DOI: 10.1089/lap.2022.0312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
Introduction: In children, gallbladder disease has become more common due to the rise in childhood obesity and subsequent shift in etiology. While the gold standard of surgical management remains a laparoscopic technique, there has been increasing interest in robotic-assisted techniques. The aim of this study is to report a 6-year update on the experience of treating gallbladder disease with robotic-assisted surgery at a single institution. Materials and Methods: A database was created to prospectively collect patient demographic and operative variables at the time of operation from October 2015 to May 2021. Descriptive analysis of select available variables was performed using median and interquartile ranges (IQRs) for all continuous variables. Results: In total, 102 single-incision robotic cholecystectomies and one single-port subtotal cholecystectomy were performed. From available data, 82 (79.6%) patients were female, median weight was 66.25 kg (IQR: 58.09-74.24 kg), and median age was 15 years (IQR: 15-18 years). Median procedure time was 84 minutes (IQR: 70.25-103.5 minutes) and median console time was 41 minutes (IQR: 30-59.5 minutes). The most frequent preoperative diagnosis was symptomatic cholelithiasis (79.6%). One (0.97%) operation was converted from a single-incision robotic approach to open. Conclusion: Single-incision robotic cholecystectomy is a safe and reliable technique for the treatment of gallbladder disease in the adolescent population.
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Affiliation(s)
- Matthew T Hey
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Mackenzie Mayhew
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Stephani Rico
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Juan Calisto
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Shahab Shaffiey
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Leopoldo Malvezzi
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Fuad Alkhoury
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Miami, Florida, USA
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17
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Ignacio RC, Kelley-Quon LI, Ourshalimian S, Padilla BE, Jensen AR, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Wang K. Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children. J Am Coll Surg 2023; 236:961-970. [PMID: 36786471 DOI: 10.1097/xcs.0000000000000650] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children. STUDY DESIGN A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05. RESULTS A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL. CONCLUSIONS Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.
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Affiliation(s)
- Romeo C Ignacio
- From the Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA (Ignacio)
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ (Padilla)
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco School of Medicine, and Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, CA (Jensen)
| | - Stephen B Shew
- Department of Pediatric General Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA (Shew)
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR (Lofberg)
| | - Caitlin A Smith
- Department of Pediatric General Surgery, Seattle Children's Hospital, Seattle, WA (Smith)
| | - Jonathan P Roach
- Department of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO (Roach)
| | - Samir R Pandya
- Department of Pediatric General and Thoracic Surgery, University of Texas Southwestern, Dallas, TX (Pandya)
| | - Katie W Russell
- Division of General Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT (Russell)
| | - Kasper Wang
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
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18
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Purcell LN, Ricketts TC, Phillips MR, Charles AG. Cholecystectomies performed in children by pediatric surgeons compared to general surgeons in North Carolina are associated with higher institutional charges. Am J Surg 2023; 225:244-249. [PMID: 35940930 DOI: 10.1016/j.amjsurg.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The delivery of pediatric surgical care for gallbladder (GB) and biliary disease involves both General Surgeons (GS) and Pediatric Surgeons (PS). There is a lack of data describing how surgeon specialty impacts practice patterns and healthcare charges. METHODS We performed a retrospective review of the North Carolina Inpatient Hospital Discharge Database (2013-2017) on pediatric patients (≤18 years) undergoing surgery for biliary pathology. We performed multivariate linear regression comparing surgeons with surgical charge. RESULTS 12,531 patients had GB or biliary pathology and 4023 (32.1%) had cholecystectomies. The most common procedure for PS and GS was cholecystectomy for cholecystitis (n = 509, 54.0% and n = 2275, 76.4%, p < 0.001), respectively. The hospital ($26,605, IQR $18,955-37,249, vs. $17,451, IQR $13,246-23,478, p < 0.001) and surgical charges ($15,465, IQR $12,233-22,203, vs. $10,338, IQR $6837-14,952, p < 0.001) were higher for PS than GS. Controlling for pertinent variables, surgical charges for PS were $4192 higher than for GS (95% CI: $2162-6122). CONCLUSION The cholecystectomy charge differential between PS and GS is significant and persisted after controlling for pertinent covariates.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Thomas C Ricketts
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA
| | - Michael R Phillips
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Anthony G Charles
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, NC, USA.
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Rauh JL, Ganapathy AS, Bosley ME, Rangecroft A, Zeller KA, Sieren LM, Petty JK, Pranikoff T, Neff LP. Making common duct exploration common-balloon sphincteroplasty as an adjunct to transcystic laparoscopic common bile duct exploration for pediatric patients. J Pediatr Surg 2023; 58:94-98. [PMID: 36283848 DOI: 10.1016/j.jpedsurg.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has well-established benefits for managing pediatric choledocholithiasis. However, providers increasingly favor ERCP pre-or-post laparoscopic cholecystectomy (ERCP+LC) due to perceived complexity of LCBDE. We refined a stepwise method employing wire-ready balloon dilation of the Sphincter of Oddi. This study compares outcomes of balloon sphincteroplasty (LCBDE+BSP) with standard transcystic LCBDE (LCBDE-STD) and ERCP+LC. METHODS We performed a retrospective chart review of pediatric patients who underwent LCBDE-STD and LCBDE+BSP since 2018. A report of consecutive choledocholithiasis patients prior to 2018 yielded an ERCP+LC cohort. Age, operative time, complications, and length of stay (LOS) were compared across all groups. Success rate and fluoroscopy time were compared between LCBDE groups. RESULTS 44 patients were identified (14:LCBDE-STD; 15:LCBDE+BSP; 15:ERCP+LC) . There was no difference in patient age or BMI. Operative time was longer in the LCBDE+BSP group (p =< 0.05). ERCP+LC demonstrated increased LOS (4.36 ± 2.78 vs 1.31 ± 0.93; p =< 0.05) and complications compared to LCBDE groups including three stent placements and one stent migration. LCBDE+BSP had a higher success rate than LCBDE-STD (100% vs 78%; p = 0.06). The three patients who failed LCBDE-STD required postoperative ERCP. Average fluoroscopy time was not significantly impacted by addition of sphincteroplasty. CONCLUSION Incorporating LCBDE into standard management of pediatric choledocholithiasis reduces LOS and avoids additional invasive procedures regardless of the specific technique employed. This stepwise approach to wire-ready cholangiography with balloon sphincteroplasty is a viable method for LCBDE that utilizes techniques familiar to pediatric surgeons and provides definitive management under a single anesthetic. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jessica L Rauh
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States.
| | - Aravindh S Ganapathy
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States
| | - Maggie E Bosley
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States
| | - Alexa Rangecroft
- Wake Forest Baptist Medical Center School of Medicine, Winston Salem, NC, United States
| | - Kristen A Zeller
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Leah M Sieren
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - John K Petty
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Thomas Pranikoff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
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Lorio E, Moreau C, Michalek JE, Patel S. Expanding the Use of Endoscopic Retrograde Cholangiopancreatography in Pediatrics: A National Database Analysis of Demographics and Complication Rates. Gastroenterology Res 2022; 15:314-324. [PMID: 36660468 PMCID: PMC9822666 DOI: 10.14740/gr1503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/21/2022] [Indexed: 12/23/2022] Open
Abstract
Background This study aimed to aid in risk assessment of pediatric endoscopic retrograde cholangiopancreatography (ERCP) candidates by utilizing a national pediatric database with a large sample to assess how patient characteristics may affect ERCP complication rates. Methods The Kids' Inpatient Database (KID) is a sample of pediatric discharges in states participating in the Healthcare Cost and Utilization Project (HCUP). This database provides demographic information, hospitalization duration, and outcome information for hospitalizations during which an ERCP occurred. International Classification of Diseases (ICD) codes were used to determine the hospitalization indication. ERCP complication rate was ascertained via ICD codes. All statistical analyses were performed using SAS 9.4. Results Complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. This analysis captured a large Hispanic population, specifically in the South and West regions. Gallbladder calculus and cholecystitis were more likely to occur in females. A higher percentage of patients in the age 10 - 17 group were female (72.2% vs. 52.7%, P < 0.01) and Hispanic (33.4% vs. 22.7%, P < 0.01) compared to the age 0 - 9 group. Age 0 - 5 and male gender were associated with lower routine home discharge rates and longer lengths of stay. Complications occurred at a higher rate in ages 0 - 5, though the difference was not statistically significant. Conclusions ERCP is a safe procedure for pediatric patients with low complication rates and rare mortality. We found statistically significant differences in the procedure indications between pediatric age groups, races, and genders. Age ≤ 5 years and male gender were associated with more complicated healthcare courses.
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Affiliation(s)
- Eric Lorio
- Department of Gastroenterology and Hepatology, Tulane University School of Medicine, New Orleans, LA, USA,Corresponding Author: Eric Lorio, Department of Gastroenterology and Hepatology, Tulane University School of Medicine, New Orleans, LA 70112, USA.
| | - Chris Moreau
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Texas Health San Antonio, TX, USA
| | - Joel Edmund Michalek
- Department of Population Health Sciences, University of Texas Health San Antonio, TX, USA
| | - Sandeep Patel
- Advanced Endoscopy Program, University of Texas Health San Antonio, TX, USA,Department of Gastrointestinal Endoscopy, University Hospital, San Antonio, TX, USA,CHRISTUS Health, San Antonio, TX, USA
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21
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Dantes G, Keane OA, Margol M, Thompson O, Darville G, Clifton MS, Heiss KF. Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic cholecystectomy surgery. Pediatr Surg Int 2022; 38:1517-1523. [PMID: 36069916 DOI: 10.1007/s00383-022-05195-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Enhanced recovery protocols [ERPs] standardize care and have been demonstrated to improve surgical quality in adults. We retrospectively compared outcomes before and after implementation of ERPs in children undergoing elective laparoscopic cholecystectomy [ELC] surgery. METHODS A pediatric-specific ERP was implemented for children undergoing ELC at one [C1] of the two Pediatric Surgical Centers in July 2016. We retrospectively reviewed 606 patients undergoing ELC between July 2014 and December 2019. Of these, 206 patients underwent ELC prior to ERP implementation [Pre-ERP] were compared to 400 patients undergoing ELC managed in the post-ERP implementation period (between January 2017 and December 2019), 21 of which were managed by enhanced recovery protocol. Primary Outcomes included immediate peri-operative and post-operative narcotic use in mean morphine equivalents [MME], narcotics at discharge, complications, nurse calls and returns to system [RTS]. RESULTS There was a significant decrease in opioid use both post-operatively and at time of discharge in the ERP managed cohort. The MME use during the post-operative period was 0.85 in the in ERP-compliant patients compared to 6.40 in the non-compliant group (p < 0.027). Eighty-six percent of ERP-compliant patients in the study required no narcotics at discharge, which was statistically significant when compared to ERP non-compliant cohort (p < 0.0001). There was also no change in RTS, nurse calls or complications. In addition, in the post-ERP period (2017-2019), a dominant proportion of patients at C1 partially complied with the ERP, resulting in a statistically significantly decrease of opioid use between sites in the post-op period (6.54 vs 10.57 MME) post-ERP (p < 0.001). Similar effects were noted in discharge narcotics. CONCLUSION The use of pediatric-specific ERP in children undergoing ELC is safe, effective, and provides compassionate pain control while leading to a reduction in opioid use peri-operatively and at discharge. This improvement occurred without changes in RTS, nursing calls or complications. LEVEL OF EVIDENCE Level III; Retrospective study.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Olivia A Keane
- Department of Pediatrics, Children's Healthcare of Atlanta, GI Care for Kids, Atlanta, GA, USA
| | - Matthew Margol
- Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Gregory Darville
- Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Kazi FN, Ghosh S, Sharma JVP, Saravanan S, Patil S. Trends in Gallbladder Disease in Young Adults: A Growing Concern. Cureus 2022; 14:e28555. [PMID: 36059300 PMCID: PMC9423860 DOI: 10.7759/cureus.28555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/13/2022] Open
Abstract
Millennials (age: 25-32 years) and Generation-Z individuals (age: 10-25 years) exhibit a shift in the occurrence of gallbladder diseases, which may be related to changes in lifestyle and genetics. In light of these findings, we performed a retrospective observational study on patients who underwent gallbladder surgeries to determine the trend in gallbladder diseases in young adults. Both categorical and continuous data on 90 patients were collected between January 2020 and June 2021 and analysed retrospectively, with differences considered significant at a p-value of 0.05. The diagnosis of gallstones in young adults is presently complicated, as the signs and symptoms of biliary tract sickness differ significantly between those under and over 30 years of age. We observed that gallbladder diseases and their complications were highly common in individuals between the ages of 21 and 25 years. We discovered that gallstones were more common in teenagers than previously thought. Delays in intervention resulted in future complications which could have been avoided.
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Nascimento JHFD, Tomaz SC, Souza-Filho BMD, Vieira ATS, Andrade ABD, Gusmão-Cunha A. A POPULATION STUDY ON GENDER AND ETHNICITY DIFFERENCES IN GALLBLADDER DISEASE IN BRAZIL. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 35:e1652. [PMID: 35730881 PMCID: PMC9254611 DOI: 10.1590/0102-672020210002e1652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 02/03/2022] [Indexed: 01/11/2023]
Abstract
Gallbladder diseases (GBD) are one of the most common medical conditions
requiring surgical intervention, both electively and urgently. It is widely
accepted that sex and ethnic characteristics mighty influence both prevalence
and outcomes.
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Affiliation(s)
| | - Selton Cavalcante Tomaz
- Universidade do Estado da Bahia, Departamento de Ciências da Vida - Salvador - Bahia - Brasil
| | | | | | - André Bouzas de Andrade
- Universidade do Estado da Bahia, Departamento de Ciências da Vida - Salvador - Bahia - Brasil
| | - André Gusmão-Cunha
- Universidade do Estado da Bahia, Departamento de Ciências da Vida - Salvador - Bahia - Brasil.,Universidade Federal da Bahia, Faculdade de Medicina da Bahia - Salvador - Bahia - Brazil
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Index Admission Cholecystectomy and Recurrence of Pediatric Gallstone Pancreatitis: Multicenter Cohort Analysis. J Am Coll Surg 2022; 234:352-358. [PMID: 35213498 DOI: 10.1097/xcs.0000000000000062] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We aim to evaluate recurrence rates of gallstone pancreatitis in children undergoing early vs interval cholecystectomy. STUDY DESIGN A multicenter, retrospective review of pediatric patients admitted with gallstone pancreatitis from 2010 through 2017 was performed. Children were evaluated based on timing of cholecystectomy. Early cholecystectomy was defined as surgery during the index admission, whereas the delayed group was defined as no surgery or surgery after discharge. Outcomes, recurrence rates, and complications were evaluated. RESULTS Of 246 patients from 6 centers with gallstone pancreatitis, 178 (72%) were female, with mean age 13.5 ± 3.2 years and a mean body mass index of 28.9 ± 15.2. Most (90%) patients were admitted with mild pancreatitis (Atlanta Classification). Early cholecystectomy was performed in 167 (68%) patients with no difference in early cholecystectomy rates across institutions. Delayed group patients weighed less (61 kg vs. 72 kg, p = 0.003) and were younger (12 vs. 14 years, p = 0.001) than those who underwent early cholecystectomy. However, there were no differences in clinical, radiological, or laboratory characteristics between groups. There were 4 (2%) episodes of postoperative recurrent pancreatitis in the early group compared with 22% in the delayed group. More importantly, when cholecystectomy was delayed more than 6 weeks from index discharge, recurrence approached 60%. There were no biliary complications in any group. CONCLUSIONS Cholecystectomy during the index admission for children with gallstone pancreatitis reduces recurrent pancreatitis. Recurrence proportionally increases with time when patients are treated with a delayed approach.
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Wong MCY, Incerti F, Avanzini S, Palo F, Sertorio F, Damasio MB, Arrigo S, Gandullia P, Mattioli G. Cholelithiasis management in a third-level pediatric center: case series and literature review. Updates Surg 2022; 74:963-968. [DOI: 10.1007/s13304-021-01227-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/22/2021] [Indexed: 01/26/2023]
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Adeniyi OF, Akinsete AM, Odeghe EA, Olowoyeye OA, Okeke OF, Seyi-Olajide JO, Akinsulie A. Cholelithiasis in children and adolescents with sickle cell disease: Experience in a resource-limited setting. Ann Afr Med 2022; 21:58-64. [PMID: 35313407 PMCID: PMC9020627 DOI: 10.4103/aam.aam_81_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/09/2020] [Accepted: 02/23/2021] [Indexed: 11/04/2022] Open
Abstract
Background Sickle cell disease (SCD) remains prevalent in Nigeria and can be complicated by cholelithiasis even in children. There is still a dearth of knowledge about the occurrence of cholelithiasis in these children. The present study is aimed to determine the prevalence of cholelithiasis in pediatric SCD in Lagos and documents relevant socio-demographic and clinical correlates. Subjects and Methods This was a cross-sectional study of children and adolescents aged 1-19 years with SCD attending the Paediatric Haematology Clinic of the Lagos University Teaching Hospital. One hundred and forty-seven children were consecutively recruited into the study over 3 months and they all had sonographic examination of the gall bladder. The association between cholelithiasis, sociodemographic data, clinical symptoms, laboratory parameters, and the use of hydroxyurea was also documented. Results The median age (range) of the study participants was 9.0 (1-19) years and majority were males (59.9%). The prevalence of cholelithiasis was 13.6% and the condition was most prevalent in adolescents (21.4%) compared to the younger children (6.5%). All the children with cholelithiasis were asymptomatic. Age and the frequency of crisis were significantly associated with cholelithiasis on multivariate analysis (P = 0.03, 0.045, respectively). The use of hydroxyurea was not significantly related to the occurrence of cholelithiasis. Conclusion The prevalence of cholelithiasis observed in this study is high. Routine screening of older children and adolescents with SCD, especially with the frequent crisis is suggested. Longitudinal studies to establish the relationship between hydroxyurea and cholelithiasis is also advocated.
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Affiliation(s)
- Oluwafunmilayo Funke Adeniyi
- Department of Paediatrics, Paediatric Gastroenterology Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Idi-Araba, Nigeria
| | - Adeseye Micheal Akinsete
- Department of Paediatrics, Paediatric Gastroenterology Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Idi-Araba, Nigeria
| | - Emuobor Aghoghor Odeghe
- Department of Internal Medicine, Gastroenterology Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Omodele Abosede Olowoyeye
- Department of Radiology, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Ogonna Faustina Okeke
- Department of Radiology, Lagos University Teaching Hospital, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | | | - Adebola Akinsulie
- Department of Paediatrics, Oncology Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Idi-Araba, Nigeria
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Doud A, Bond L, Downard C, Vitale G, Fallat M, Foley D, Wright T, Bond S. Management of complicated biliary disease in the pediatric population. Surgery 2021; 171:736-740. [PMID: 34844759 DOI: 10.1016/j.surg.2021.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/23/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cholesterol stones and biliary dyskinesia have replaced hemolytic disease as the primary indication for pediatric cholecystectomy. This study looks at the cohort of pediatric patients with complicated biliary disease, defined as choledocholithiasis and/or gallstone pancreatitis, to determine the incidence and best treatment options. METHODS A retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children's hospital was performed. Patient factors, indications for cholecystectomy, and final treatment were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High-risk patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase. RESULTS A total of 695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. Of the 695 cholecystectomies, 457 were performed for stone disease (66%) (64 hemolytic) and 236 (34.0%) were performed for biliary dyskinesia. Hundred and three (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated disease). In high-risk patients, 28/47 (59.6%) underwent endoscopic retrograde cholangiopancreatography/sphincterotomy. In low-risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required endoscopic retrograde cholangiopancreatography/sphincterotomy (P < .05). The indication for endoscopic retrograde cholangiopancreatography after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications. CONCLUSION The incidence of pediatric complicated biliary disease due to cholesterol stones is equal to that of adults. These data suggest that a patient with imaging evidence of choledocholithiasis or common bile duct enlargement may require endoscopic retrograde cholangiopancreatography, dependent on clinical course, and this should be strongly considered before cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative endoscopic retrograde cholangiopancreatography if needed.
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Affiliation(s)
- Andrea Doud
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Logan Bond
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Cynthia Downard
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Gary Vitale
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Mary Fallat
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - David Foley
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Tiffany Wright
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY
| | - Sheldon Bond
- Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, KY.
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Abstract
PURPOSE The prevalence of gallstones in children has increased over the last years. Choledocholithiasis (CD) is present in up to 30% of the cases. There is a scarcity of studies on the management of choledocholithiasis in children. The aim of this study was to develop a score that would allow predicting accurately the risk of CD in children with gallstones and reduce the number of non-therapeutic ERCP. MATERIALS AND METHODS We conducted a retrospective study in children with gallstones and suspected CD seen between January 2010 and December 2019. The main outcome was the presence of CD confirmed by at least one of the following diagnostic tests: magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and/or intraoperative cholangiography (IOC). We developed a risk score based on the presence or absence of the following risk factors: acute biliary pancreatitis, ascending cholangitis, elevated liver function tests (AST, ALT, total bilirubin [TB, ≥ 2 mg/dl], conjugated bilirubin, gamma-glutamyl transpeptidase, and alkaline phosphatase), CD on ultrasound (US; this was considered predictive but not confirmatory of CD), and dilation of the common bile duct (> 6 mm) by US. The score was divided into three different categories: low risk (no risk factors), intermediate risk (one risk factor present), high risk (≥ 2 risk factors present or ascending cholangitis). Given the main goal of reducing the number of diagnostic ERCPs, a very-high-risk subgroup (3 risk factors present or ascending cholangitis) was identified. RESULTS We reviewed 133 patients with gallstones and suspected CD. In 56 (42.1%) patients, the presence of CD was confirmed by one or more of the definitive diagnostic tests (MRCP, ERCP, and IOC). The following variables were found to be the strongest predictors of CD: ascending cholangitis, TB ≥ 2 mg/dl, common bile duct > 6 mm, and the presence of CD by US. The positive predictive value for CD was 7.5% in the low-risk group (OR 0.06, P = < 0.001); 22.9% in the intermediate-risk group (OR 0.31, P = 0.007); 77.6% in the high-risk group (OR 20.14, P = < 0.001); and 95.7% in very-high-risk subgroup (OR 49.18, P = < 0.001). CONCLUSION The risk score proposed in this study predicts accurately the presence of CD in children with gallstones. It can serve as a helpful tool to triage the need for costly and complex studies in the workup of CD, particularly in centers with limited resources. Finally, due to its high specificity and positive predictive value (PPV), the use of the very-high-risk criteria would allow for an important decrease in the number of non-therapeutic ERCP.
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Bosley ME, Jacobson J, Gaffley MWG, Beckwith MA, Pandya SR, Davis JS, Neff LP. Biliary hyperkinesia in adolescents-it isn't all hype! Transl Gastroenterol Hepatol 2021; 6:36. [PMID: 34423157 DOI: 10.21037/tgh-20-258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022] Open
Abstract
Background Biliary dyskinesia generally refers to a hypofunctioning gallbladder with an ejection fraction (EF) of <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA testing). In adults, biliary hyperkinesia has a defined association with biliary colic symptoms and can be relieved with surgical intervention. This clinical entity has not been well described in children or adolescents. In fact, only recently have we seen biliary hyperkinesia on HIDA at our centers. To that end, we reviewed our recent experience with adolescents who have presented and been treated for this unusual clinical entity. Methods With IRB approval, we retrospectively reviewed the records of all patients with abnormally high HIDA EFs (>80%) cared for by the pediatric surgery services at two tertiary care centers over the span of a three-year period. Age, sex, BMI, CCK-HIDA results, and preoperative testing and post-operative pathology were noted. Resolution of symptoms was determined by subjective patient self-reporting at postoperative visit. Results Eighteen patients met inclusion criteria. Average age 15.7 (range, 10-17 years), median BMI 27.3 (±8.2). Fifteen patients were female and 3 were male. Average CCK-HIDA EF was 91.6% (±5.2), 82.4% of the patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology. Postoperatively, 82.4% of the patients available for follow up (n=17) reported complete or near complete resolution of symptoms. Conclusions Biliary hyperkinesia is an emerging clinical entity in children and adolescents and has a similar presentation to biliary hypokinesia. While the pathophysiologic mechanism of pain is not fully elucidated, laparoscopic cholecystectomy appears to provide a surgical cure for these patients and should be considered in the differential for the patient with an unremarkable workup and history suggestive of biliary colic.
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Affiliation(s)
- Maggie E Bosley
- Department of General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Jillian Jacobson
- Department of General Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Michaela W G Gaffley
- Department of General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Michael A Beckwith
- Department of General Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samir R Pandya
- Division of Pediatric Surgery, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
| | - James S Davis
- Division of Pediatric Surgery, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
| | - Lucas P Neff
- Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, NC, USA
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Gallbladder Interleukins in Children with Calculous Cholecystitis. Pediatr Rep 2021; 13:470-482. [PMID: 34449702 PMCID: PMC8396171 DOI: 10.3390/pediatric13030054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/06/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022] Open
Abstract
Calculous cholecystitis connects to inflammation and various complications. It is a common disease in the paediatric population, yet it is still uncertain how inflammation factors are involved in its morphopathogenesis. Twenty calculous cholecystitis surgery tissue samples were obtained from 20 children. As a control, seven unaffected gallbladders were used. Tissues were immunohistochemically stained for IL-1α, IL-4, IL-6, IL-7, IL-8, IL-10, and IL-17A, and the slides were inspected by light microscopy. To evaluate statistical differences and correlations between interleukins, Mann-Whitney U and Spearman's tests were used. Statistically significant difference between patient and control gallbladder epithelium was for IL-1α and IL-17A, but connective tissue-IL-1α, IL-4, IL-6, IL-7, IL-8, and IL-17A positive structures. A strong positive correlation in patients was detected between epithelial IL-1α and IL-1α in connective tissue, epithelial IL-6 and IL-7, IL-6 and IL-17A, IL-7 and IL-10, IL-7 and IL-17A, as well as between IL-6 and IL-7, IL-7 and IL-10 in connective tissue. The increase of IL-1α, IL-4, IL-6, IL-7, IL-8 and IL-17A positive structures suggests their role in the morphopathogenesis of calculous cholecystitis. The correlations between interleukins in epithelium and in connective tissues prove that the epithelial barrier function and inflammatory response in deeper layers are sustained through intercellular signalling pathways.
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Bhaumik K. Asymptomatic Cholelithiasis in Children: Management Dilemma. J Indian Assoc Pediatr Surg 2021; 26:228-233. [PMID: 34385765 PMCID: PMC8323576 DOI: 10.4103/jiaps.jiaps_107_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/26/2020] [Accepted: 05/08/2020] [Indexed: 11/04/2022] Open
Abstract
Aims and Objectives: The incidence of cholelithiasis is now increasing in children. Besides hemolytic diseases, there are also nonhemolytic conditions and idiopathic group. A large number of children belong to asymptomatic group who do not present with gallstone-related symptoms. There is no consensus in the management of these children. The aim of this study is to evaluate the role of elective cholecystectomy in asymptomatic cases to prevent complications which leads to more morbidity. Materials and Methods: One hundred and seventy-eight children were treated over a period of 12 years and they were divided into two groups according to their age at presentation. Sixty-four children below 5 years belonged to Group A and 114 children between 5 and 12 years belonged to Group B. About 71.8% of children of Group A and 49.1% of children of Group B were asymptomatic. Cholecystectomy was advised in all cases of Group B and all symptomatic cases of Group A. In Group A asymptomatic cases, ursodeoxycholic acid (UDCA) was given for 6–12 months and followed up. Results: Laparoscopic cholecystectomy was performed in all cases except in five cases where conversion to open surgery was done as there was gross adhesions due to previous laparotomy. Of 46 asymptomatic cases of Group A, the stone disappeared in seven cases, 12 children developed symptoms, and there was no change in 27 patients. Stone reappeared again in three of seven children who were managed by cholecystectomy. Cholecystectomy was also performed in 12 cases that developed symptoms. In the rest of the 27 children, cholecystectomy was advised after 1 year trial of UDCA. Cholecystectomy was advised in both symptomatic and asymptomatic cases of Group B. Sixteen of 56 asymptomatic cases did not agree for cholecystectomy and 12 of them returned with complications. Endoscopic retrograde cholangio-pancreaticography (ERCP) and stone extraction was performed in four cases. In all the acute cases, cholecystectomy was performed after a period of conservative management. Conclusion: UDCA can be tried in the smaller age group below 5 years, but there is a chance of recurrent stone formation. Elective laparoscopic cholecystectomy should be the choice in all asymptomatic cases to prevent complications.
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Affiliation(s)
- Kuntal Bhaumik
- Department of Pediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India
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Lee H, Koh DH. [Obesity and Pancreatobiliary Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 75:240-245. [PMID: 32448855 DOI: 10.4166/kjg.2020.75.5.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 01/04/2023]
Abstract
Obesity has become a major medical and public health problem worldwide. Recent studies have shown that obesity is a chronic disease that is associated with many diseases, such as gallstone disease, acute pancreatitis, fatty liver, and digestive cancer. Obesity is also a risk factor for the formation of cholesterol gallstones. Clinical and epidemiological studies have suggested that obesity is positively associated with the risk of gallbladder cancer. Obesity may modulate the lipid and endogenous hormones metabolism, affect gallbladder motility, increase the risk of gallstones, and increased the risk of gallbladder cancer. In addition, obesity has been considered a risk factor for pancreatic diseases, including pancreatitis and pancreatic cancer. Obese patients develop systemic and local complications of acute pancreatitis more frequently. Several epidemiologic studies have suggested an association of pancreatic cancer with high body mass and lack of physical activity. This study reviewed the literature on obesity and pancreatobiliary disease in terms of epidemiology and mechanism.
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Affiliation(s)
- Hoongoo Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
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Diez S, Müller H, Weiss C, Schellerer V, Besendörfer M. Cholelithiasis and cholecystitis in children and adolescents: Does this increasing diagnosis require a common guideline for pediatricians and pediatric surgeons? BMC Gastroenterol 2021; 21:186. [PMID: 33882844 PMCID: PMC8061037 DOI: 10.1186/s12876-021-01772-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background In contrast to adults, for whom guidelines on the cholelithiasis treatment exist, there is no consistent treatment of pediatric patients with cholelithiasis throughout national and international departments, most probably due to the lack of evidence-based studies. Methods We evaluated the German management of pediatric cholelithiasis in a dual approach. Firstly, a retrospective, inter-divisional study was established, comparing diagnostics and therapy of patients of the pediatric surgery department with the management of patients aged < 25 years of the visceral surgery department in our institution over the past ten years. Secondarily, a nation-wide online survey was implemented through the German Society of Pediatric Surgery. Results Management of pediatric patients with cholelithiasis was primarily performed by pediatricians in the retrospective analysis (p < 0.001). Pediatric complicated cholelithiasis was not managed acutely in the majority of cases with a median time between diagnosis and surgery of 22 days (range 4 days–8 months vs. 3 days in visceral surgery subgroup (range 0 days–10 months), p = 0.003). However, the outcome remained comparable. The hospital’s own results triggered a nation-wide survey with a response rate of 38%. Primary pediatric medical management of patients was confirmed by 36 respondents (71%). In case of acute cholecystitis, 22% of participants perform a cholecystectomy within 24 h after diagnosis. Open questions revealed that complicated cholelithiasis is managed individually. Conclusions The management of pediatric cholelithiasis differs between various hospitals and between pediatricians and pediatric surgeons. Evidence-based large-scale population studies as well as a common guideline may represent very important tools for treating this increasing diagnosis. Supplementary information The online version contains supplementary material available at 10.1186/s12876-021-01772-y.
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Affiliation(s)
- Sonja Diez
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Pediatric Surgery, Department of Surgery, University Hospital Erlangen, Erlangen, Germany.
| | - Hanna Müller
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Neonatology and Intensive Care Unit, Children's Hospital Erlangen, University Hospital Erlangen, Erlangen, Germany.,Philipps-Universität Marburg, Neonatology and Pediatric Intensive Care, Department of Pediatrics, University of Marburg, Marburg, Germany
| | - Christel Weiss
- Ruprecht-Karls-Universität Heidelberg, Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Vera Schellerer
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Pediatric Surgery, Department of Surgery, University Hospital Erlangen, Erlangen, Germany.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), General and Visceral Surgery, Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Manuel Besendörfer
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Pediatric Surgery, Department of Surgery, University Hospital Erlangen, Erlangen, Germany
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Gao K, Zheng C, Han H, Guo C. A Multicenter Randomized Prospective Study of Early Cholecystectomy for Pediatric Patients with Biliary Colic. J Gastrointest Surg 2021; 25:713-719. [PMID: 32935270 DOI: 10.1007/s11605-020-04700-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/11/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with biliary colic, high-quality prospective data supporting the precise timing of cholecystectomy are lacking. The purpose of this study was to determine the effectiveness of early laparoscopic cholecystectomy in children with biliary colic. METHODS A multicenter, parallel-group, randomized study was conducted in patients with biliary colic at 5 hospitals in China. Pediatric patients with biliary colic were prospectively randomized to either the early cholecystectomy or conservative management strategy. The clinical outcomes within 6 months, including the number of biliary colic-free patients and gallstone-related complications, were compared (register number ChiCTR1900021830). RESULTS During the first 2 months of follow-up, 71 patients (59.2%, 71/120) receiving conservative management and 124 patients (97.6%, 124/127) in the early cholecystectomy group (p < 0.001) reported being entirely colic-free. The GIQLI measures were higher in the early cholecystectomy group than in the conservative management group (p = 0.032). Acute readmissions occurred in 7 (5.5%) of 127 patients in the early cholecystectomy group, compared with 23 (19.2%) of 120 patients in the conservative management group (risk ratio [RR] 0.25; 95% CI [0.10-0.60], p = 0.001) in the 6-month period. CONCLUSIONS Early cholecystectomy is effective in providing beneficial outcomes in terms of both short-term and long-term improvement of symptoms.
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Affiliation(s)
- Kai Gao
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China
| | - Chao Zheng
- Department of Orthopedics, Children's Hospital, Chongqing Medical University, Chongqing, 400014, People's Republic of China
| | - Huanli Han
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China.
| | - Chunbao Guo
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China.
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Khan FA, Markwith N, Islam S. What is the role of the cholecystokinin stimulated HIDA scan in evaluating abdominal pain in children? J Pediatr Surg 2020; 55:2653-2656. [PMID: 32482410 DOI: 10.1016/j.jpedsurg.2020.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Cholecystokinin stimulated HIDA (CCK-HIDA) has been used to identify patients with biliary dyskinesia and select patients likely to benefit from cholecystectomy. The appropriate use of this study in children remains controversial and this study aims to better understand the utility of this test. METHODS Children who underwent a CCK-HIDA for evaluation of abdominal pain over a 15-year period were included, after excluding infants and patient's s/p liver transplant. Relevant clinical and outcomes data were abstracted and analyzed. RESULTS 124 patients met inclusion criteria. Mean age was 14.5 ± 2.6 years, Mean BMI was 27.9 ± 9.9 and 96 (77.4%) presented with right upper quadrant or epigastric pain. The mean ejection fraction (EF) was 58.5 ± 31.8%, with 37 (29.8%) < 35% EF. Using receiver operating curve analysis no specific EF threshold value predictive of resolution of symptoms was identified (AUC 0.510; p = 0.94). Using EF <35% and >35% and <20% and >20%, no association was noted with partial/complete resolution of symptoms. On multivariate regression analysis neither EF nor pain reproduction with CCK administration were independently associated with resolution of symptoms. CONCLUSIONS These data suggest that the CCK-HIDA scan is a poor predictor of benefit from cholecystectomy. Prospective large studies would help in identifying better criterion for patient selection, especially with the trend of increasing surgery for functional gallbladder disorders. TYPE OF STUDY Case cohort. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Faraz A Khan
- Division of Pediatric Surgery, Loma Linda University, Loma Linda, CA.
| | - Nicole Markwith
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL.
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Weng SC, Lee HC, Yeung CY, Chan WT, Liu HC, Jiang CB. Choledochal cyst as an important risk factor for pediatric gallstones in low-incidence populations: A single-center review. Pediatr Neonatol 2020; 61:598-605. [PMID: 32773363 DOI: 10.1016/j.pedneo.2020.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/15/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Gallstones are uncommon in infants and children and Asian children are thought to have very low risk. Diagnoses have increased in recent years with the widespread use of ultrasonography (USG). This study aimed to review our experience with risk factors, complications, and treatment of pediatric gallstones in low-incidence populations. METHODS We retrospectively reviewed patients younger than 18 years old diagnosed with gallstones using USG between November 2006 and December 2012 in a tertiary referral hospital in Taiwan. Demographic information including age and sex, follow-up period, USG findings, predisposing factors, complications, treatment approaches and outcomes were recorded. RESULTS Ninety-eight children with gallstones diagnosed with USG were enrolled and reviewed in our study. Females comprised 55% of patients, with no specific gender tendency. No risk factor could be identified in 30.8% of patients. The most common risk factors were cephalosporin (CS) use, presence of a choledochal cyst (CC), and spherocytosis. CS use was not associated with a higher dissolution rate. The presence of type IVa CC implied a high rate of gallstone recurrence after Roux-en-Y hepaticojejunostomy. Complications were seen in 22.4% of patients, but only two needed emergency stone removal. Expectant management was performed in 61% of patients and 62.5% of them achieved spontaneous resolution; the stone dissolution rate was not lower than in the group treated with ursodeoxycholic acid (UDCA). Stone size was significantly decreased after UDCA use if resolution did not occur. CONCLUSIONS Pediatric gallstones showed high resolution rate, and the clinical course was largely benign. CS use was the most common risk factor and did not predict a higher dissolution rate. Type IVa CC was also an important risk factor associated with a high recurrence rate. Conservative treatment and oral UDCA may be reasonable strategies in most patients, unless complications are present.
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Affiliation(s)
- Shu-Chao Weng
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, MacKay Children's Hospital, Taipei, Taiwan; Department of Pediatrics, Taitung Mackay Memorial Hospital, Taitung County, Taiwan.
| | - Hung-Chang Lee
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, MacKay Children's Hospital, Taipei, Taiwan.
| | - Chun-Yan Yeung
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, Taipei, Taiwan.
| | - Wai-Tao Chan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, MacKay Children's Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan.
| | - Hsi-Che Liu
- Department of Medicine, Mackay Medical College, Taipei, Taiwan; Department of Hematology-Oncology, MacKay Children's Hospital, Taipei, Taiwan.
| | - Chuen-Bin Jiang
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, Taipei, Taiwan.
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Lee YJ, Park YS, Park JH. Cholecystectomy is Feasible in Children with Small-Sized or Large Numbers of Gallstones and in Those with Persistent Symptoms Despite Medical Treatment. Pediatr Gastroenterol Hepatol Nutr 2020; 23:430-438. [PMID: 32953638 PMCID: PMC7481062 DOI: 10.5223/pghn.2020.23.5.430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/01/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We investigated the clinical features and factors affecting the choice of treatment modality and the course of pediatric gallstone (GS) disease. METHODS We retrospectively analyzed the medical records of 65 patients diagnosed with GS using imaging studies between January 2009 and December 2017 were included. RESULTS This study included 65 patients (33 boys and 32 girls; mean age, 8.5±5.3 years; range, 0.2-18 years) who primarily presented with abdominal pain (34%), jaundice (18%), and vomiting (8%). Idiopathic GS occurred in 36 patients (55.4%). The risk factors for GS included antibiotic use, obesity, hemolytic disease, and chemotherapy in 8 (12.3%), 7 (10.8%), 6 (9.2%), and 4 patients (6.2%), respectively. We observed multiple stones (including sandy stones) in 31 patients (47.7%), a single stone in 17 (26.2%), and several stones in 17 (26.2%). GS with a diameter of <5 mm occurred in 45 patients (69.2%). Comorbidities included hepatitis, choledocholithiasis, cholecystitis, and acute pancreatitis in 20 (30.8%), 11 (16.9%), 11 (16.9%), and 4 patients (6.2%), respectively. Ursodeoxycholic acid (UDCA) was administered to 54 patients (83.1%), leading to stone dissolution in 22 patients (33.8%) within 6 months. Cholecystectomy was performed in 18 patients (27.7%) (mean age, 11.9±5.1 years). Most patients treated surgically had multiple stones (83%) and stones measuring <5 mm in size (89%), and 66.7% of patients had cholesterol stones. CONCLUSION Cholecystectomy is feasible in patients with small-sized or large numbers of GS and those with persistent abdominal pain and/or jaundice. UDCA administration with close follow-up is recommended in patients with uncomplicated GS.
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Affiliation(s)
- Yeoun Joo Lee
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Yeh Seul Park
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae Hong Park
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
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Same Anesthesia Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: The Pediatric ERCP Database Intiative Experience. J Pediatr Gastroenterol Nutr 2020; 71:203-207. [PMID: 32732788 DOI: 10.1097/mpg.0000000000002722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Successful combined Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) in the Same Session (LESS) has been reported in several studies in adult patients with choledocholithiasis. METHODS This was a retrospective analysis of data collected prospectively in the Pediatric ERCP Database Initiative using REDCAP. Adverse events were recorded separately and were reviewed for this study. The primary outcome was the hospitalization days. Secondary outcomes included total duration of anesthesia, morbidity, time from diagnosis to procedure. RESULTS Twenty-five patients underwent LESS, and 42 underwent the traditional ERCP followed by laparoscopic cholecystectomy. The groups were similar in age, weight, ASA. The median length of stay in the LESS group was 3 days, compared with 4 days (P = .32). Total procedure time was similar between the 2 groups, but anesthesia time was shorter in the LESS group (P = .0401). Morbidity was similarly low between the 2 groups. CONCLUSIONS Relative to 2 interventions, a single session combining ERCP and laparoscopic cholecystectomy in pediatric patients is effective with a similar adverse event rate and length of stay. The use of a single sedation and reduced total anesthesia time are potential benefits of this approach. This modality may be considered for pediatric patients with choledocholithiasis with or without hemolytic disease.
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Gee KM, Rosenberg D, Kim ES. Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis. J Surg Res 2020; 252:133-138. [PMID: 32278967 PMCID: PMC11182379 DOI: 10.1016/j.jss.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis. METHODS After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression. RESULTS Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007). CONCLUSIONS Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.
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Affiliation(s)
- Kristin M Gee
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - David Rosenberg
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California.
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Enayet A, Afifi RA, Mogahed EA, El-Raziky MS, Abdellatif MAK. Gallstones in Egyptian infants and children: risk factors, complications and outcome: a single center experience. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00037-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
The widespread use of abdominal ultrasonography in children documented increased detection rate of gallstones. The aim of this study was to assess the possible risk factors of gallstones and to detect the complication rate and outcome of the disease in Egyptian infants and children from a hepatologist perspective. This prospective study included 35 cases, with ultrasound-detected gallstones, who presented to the Pediatric Hepatology Unit from July 2015 to October 2017. All patients were initially evaluated by full history, general and abdominal examination, laboratory assessment, and ultrasound findings to detect possible risk factors of gallstones. Management approach was individualized for each patient according to his/her condition, and the patients were followed up at 3 months interval.
Results
The patients’ ages ranged from 3.5 months up to 17 years. The median age of gallstone detection was 2 years. Gallstones were symptomatic in 62.9% with abdominal pain in 51.4%. Complications in the form of choledocholithiasis were detected in 7 patients (20%). Laparoscopic cholecystectomy was done for 7 patients while conservative management was applied for 24 patients. Complete resolution occurred in 8.3% and partial resolution in 33.3%. Chronic hemolytic anemia was the most commonly identified risk factor for gallstones. Patients needed surgical intervention had significant higher serum cholesterol and LDL levels (P = 0.006 and P = 0.002 respectively).
Conclusion
Risk factors for gallstones could be identified in most of pediatric cases. Symptomatic presentation is common among the pediatric population. Conservative management is recommended for asymptomatic cases of gallstones in children. Laparoscopic cholecystectomy is a safe and recommended procedure for complicated and symptomatic cases of gallstones.
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Tucker JJ, Grim R, Bell T, Martin J, Ahuja V. Changing Demographics in Laparoscopic Cholecystectomy Performed in the United States: Hospitalizations from 1998 to 2010. Am Surg 2020. [DOI: 10.1177/000313481408000718] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
In the clinical experience at a community hospital, younger patients appear to be receiving more laparoscopic cholecystectomy (LC). The purpose of this study was to determine if LC is increasing in the younger patient population and if obesity is associated with the increase in LC. Patients undergoing LC were identified from the Healthcare Cost Utilization Project Nationwide Inpatient Sample database. There were 4,449,643 LCs from 1998 to 2010. Patients 15 to 24 years of age had the largest increase in LC (3.2%) and obesity (10.8%) from 1998 to 2010. In the 15- to 24-year age group, the following variables were associated with obesity: female, white, private payer, nonteaching hospital, urban location, southern region, large hospital bed size, and 31 Charlson group, all P < 0.05. Additionally in the 15- to 24-year age group, median length of stay (nonobese 2 days vs obese 3 days) and median cost (nonobese $19,170 vs obese $22,802) were both increased ( P < 0.001). The percentage of younger people having LC is increasing with highest increases in the obese population. The obese youth also have longer length of stay with an increase in hospital cost. These results suggest a rising disease burden associated with obesity among people ages 15 to 24 years. Gallstone disease burden will likely increase with the increase in prevalence of obesity and would add to healthcare economic burden.
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Affiliation(s)
| | - Rod Grim
- Department of Surgery, York Hospital, York, Pennsylvania
| | - Ted Bell
- Department of Surgery, York Hospital, York, Pennsylvania
| | | | - Vanita Ahuja
- Department of Surgery, York Hospital, York, Pennsylvania
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Pancreatitis in pre-adolescent children: a 10 year experience in the pediatric emergency department. BMC Emerg Med 2019; 19:71. [PMID: 31752694 PMCID: PMC6868791 DOI: 10.1186/s12873-019-0281-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023] Open
Abstract
Background The diagnosis of pediatric pancreatitis has been increasing over the last 15 years but the etiology of this is uncertain. The population of pre-adolescent patients with pancreatitis in the emergency department has not been specifically described. Our objective was to determine the characteristics of these patients to illuminate this population and disease in order to better identify them and avoid a delay in diagnosis and treatment. Methods This was a retrospective descriptive study of consecutive pediatric patients under the age of 13 years between 2006 and 2016 who presented to our pediatric emergency department with a diagnosis of atraumatic pancreatitis. Patient characteristics, lab and imaging results, identified etiology of pancreatitis, and recurrence rates were recorded and evaluated. Results There were 139 visits, of which 85 were for a first episode of acute pancreatitis, and 54 were patients with an episode of recurrent pancreatitis. The median age for all visits was 8 years (IQ range 5–11). Of the acute cases, 26% had uncertain or undetermined etiologies of which half were thought to likely be viral related; 20% had systemic inflammatory or autoimmune diseases; 19% were associated with medications, with the most common being valproic acid; 16% were cholelithiasis-related; and 15% were found to have a genetic, congenital or structural etiology. No patients had elevated triglycerides. Those with cholelithiasis and genetic or structural defects were found to have a higher recurrence rate than those with other etiologies. There were only four patients diagnosed with chronic pancreatitis. Conclusions The etiology of pancreatitis in pre-adolescent children has a different distribution than in adolescents and adults, with gallstone disease less frequent and concurrent contributing illness more common. Patients on pancreatitis-causing medications or with known genetic risk or structural pancreatic problems should be tested for pancreatitis if presenting with concerning symptoms. Hypertriglyceridemia and chronic pancreatitis with evidence of pancreatic exocrine insufficiency is uncommon in this population.
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Gee KM, Jones RE, Casson C, Barth B, Troendle D, Beres AL. More Is Less: The Advantages of Performing Concurrent Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography for Pediatric Choledocholithiasis. J Laparoendosc Adv Surg Tech A 2019; 29:1481-1485. [PMID: 31566486 DOI: 10.1089/lap.2019.0429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are standard of care for pediatric choledocholithiasis. Patients typically undergo separate procedures during hospitalization. Collaboration between surgical and gastroenterology services led to performance of both procedures concurrently during one anesthetic. We hypothesized that concurrent procedures would reduce costs without increasing complications as compared with separate procedures. Materials and Methods: We evaluated patients admitted to our institution from 2013 to 2018 with choledocholithiasis who underwent both ERCP and LC during the same admission. Fourteen patients underwent both procedures during concurrent anesthetic. Forty-two patients who underwent LC and ERCP under separate anesthetics were randomly selected to perform a 3:1 matched case-control study. Demographic and clinical data were collected, including imaging and laboratory findings, outcomes, and costs. Comparative analysis was completed with Fisher's exact and Mann-Whitney U tests. Results: On presentation, there was no difference in common bile duct size, total bilirubin, or white blood cell count between the concurrent and separate procedure cohorts. Significantly, there was no difference in total length of anesthesia (117.9 ± 40 minutes versus 119.6 ± 52 minutes, P = .747). There were also no differences in complications, emergency department visits, or readmissions. Patients who underwent concurrent procedures had significantly lower total cost of stay ($45,597 ± 11,513 versus $61,008 ± 17,960, P = .006). Conclusions: In pediatric patients with choledocholithiasis, performing LC and ERCP may be performed concurrently during one anesthetic, which decreases costs without increasing in anesthesia time or complications.
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Affiliation(s)
- Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cameron Casson
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bradley Barth
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Pediatric Surgery, Children's Health, Dallas, Texas
| | - David Troendle
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Pediatric Surgery, Children's Health, Dallas, Texas
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Pediatric Surgery, Children's Health, Dallas, Texas
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Akhtar-Danesh GG, Doumouras AG, Bos C, Flageole H, Hong D. Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy. JAMA Surg 2019; 153:551-557. [PMID: 29344632 DOI: 10.1001/jamasurg.2017.5461] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance The prevalence of pediatric cholelithiasis is increasing with the epidemic of childhood obesity. With this rise, the outcomes and costs of pediatric laparoscopic cholecystectomy become an important public health and economic concern. Objective To assess patient and health system factors associated with the outcomes and costs after laparoscopic cholecystectomy among Canadian children. Design, Setting, and Participants This was a retrospective, population-based study of children 17 years and younger undergoing laparoscopic cholecystectomy from April 1, 2008, until March 31, 2015. The data source was the Canadian Institute for Health Information. The Canadian Institute for Health Information Discharge Abstract Database includes data from all Canadian hospitals. The analysis was limited to inpatient cholecystectomies. All Canadian children undergoing laparoscopic cholecystectomy were included. Exposure The exposure in this study was laparoscopic cholecystectomy. Main Outcomes and Measures The primary outcome was all-cause morbidity, a composite outcome of any complication that prolonged length of stay by 24 hours or required a second, unplanned procedure. The cost of the index admission was also calculated as a secondary outcome. These outcomes of interest were determined before data analysis. Odds ratios and 95% CIs were estimated using multilevel logistic regression models. Results During the study period, 3519 laparoscopic cholecystectomies were performed; of these, 79.1% (n = 2785) were in girls, and 98.0% (n = 3450) were for gallstone disease. The overall morbidity rate was 3.9% (n = 137). After adjustment, patients with comorbidities were more susceptible to morbidity (odds ratio, 2.68; 95% CI, 1.78-3.86; P < .001). Operations for gallstones were less morbid. High-volume general surgeons had lower morbidity rates compared with low-volume pediatric surgeons (odds ratio, 0.32; 95% CI, 0.12-0.69; P = .005) independent of pediatric volumes. The mean (SD) unadjusted cost of a laparoscopic cholecystectomy was $4115 ($7273). Operative indication, complications, comorbidities, emergency admission, and surgeon volume were associated with cost. Conclusions and Relevance The high-volume nature of adult general surgery translated to lower morbidity and cost after pediatric laparoscopic cholecystectomy, suggesting that adult volume is associated with pediatric outcomes. As the rate of pediatric gallstone disease increases, surgeon volume, rather than specialty training, should be considered when pursuing operative management.
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Affiliation(s)
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cecily Bos
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Helene Flageole
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St Joseph's Healthcare, Hamilton, Ontario, Canada
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Mazur-Melewska K, Derwich A, Mania A, Kemnitz P, Służewski W, Figlerowicz M. Epstein-Barr virus infection with acute acalculous cholecystitis in previously healthy children. Int J Clin Pract 2019; 73:1-6. [PMID: 31243873 DOI: 10.1111/ijcp.13386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 06/02/2019] [Accepted: 06/23/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute acalculous cholecystitis (AAC), an inflammatory process of the gallbladder (GB) in the absence of gallstones, typically occurs in seriously ill patients. AAC can complicate primary Epstein-Barr virus (EBV) infection, but it is an atypical clinical presentation. AIM The aim of our study was to analyse AAC occurrence in children with primary symptomatic EBV infection who had been admitted to the hospital. METHODS We retrospectively evaluated the medical documentation of 181 children with EBV infection who were diagnosed based on the presence of viral capsid antigen IgM antibodies. All EBV-positive patients underwent transabdominal ultrasonography of the liver in the supine and right anterior oblique positions. Fifteen children who presented with AAC symptoms, including abdominal pain and a positive Murphy's sign, were analysed as a subsample and re-evaluated after 2-3 months. RESULTS The incidence of AAC in children hospitalised with infectious mononucleosis (IM) was estimated at 8.3%. Analysis of the laboratory results confirmed that the C-reactive protein (CRP) concentration was the only parameter which was higher in children who presented with AAC symptoms. The mean number of leucocytes and monocytes and liver enzyme activities were not significantly higher. The radiological findings of AAC were evident: increased GB wall thickness, non-shadowing echogenic sludge and pericholecystic fluid collection. CONCLUSION AAC during primary EBV infection appears to be a more common pathology than previously suspected. Its relatively mild nature and the lack of laboratory abnormalities mean that ultrasonographic examination is required for diagnosis. This might explain why the prevalence in children is underestimated.
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Affiliation(s)
- Katarzyna Mazur-Melewska
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Aleksandra Derwich
- Student Research Circle at the Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Anna Mania
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Paweł Kemnitz
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Wojciech Służewski
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Magdalena Figlerowicz
- Department of Infectious Diseases and Child Neurology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
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Lawrence AE, Deans KJ, Chisolm DJ, Wrona SK, Minneci PC, Cooper JN. Racial Disparities in Receipt of Postoperative Opioids After Pediatric Cholecystectomy. J Surg Res 2019; 245:309-314. [PMID: 31421378 DOI: 10.1016/j.jss.2019.07.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pediatric postoperative opioid prescribing has come under scrutiny as a result of the ongoing opioid epidemic. Previous research has demonstrated that African American adults are less likely to receive analgesics, particularly opioids, after surgery, even after controlling for pain severity. We sought to examine racial disparities in the filling of opioid prescriptions by pediatric surgical patients after cholecystectomy. METHODS We studied patients aged 1 to 18 y who were enrolled in Ohio Medicaid and underwent cholecystectomy. Procedures performed in January 2013-July 2016 were included. The percentage of patients who filled a postoperative opioid prescription within 14 d of their procedure was compared between black and white patients using log binomial regression models fit using generalized estimating equations to account for patient clustering within hospitals. RESULTS We identified 1277 patients who underwent a cholecystectomy. In unadjusted analyses, black children were significantly less likely than white children to fill an opioid prescription postoperatively (74.9% versus 85.7%, P < 0.001). After adjustment for patient-level clinical and demographic characteristics, we found that black children treated at non-children's hospitals in large-/medium-sized urban counties were significantly less likely to fill an opioid prescription after cholecystectomy when compared with white children treated at urban children's hospitals or to white children treated in non-children's hospitals in either large/medium urban counties or other counties. However, this association was partly explained by a longer average length of stay among black children. CONCLUSIONS Black children who undergo cholecystectomy at urban non-children's hospitals are less likely to fill a postoperative opioid prescription than white children who undergo cholecystectomy at those same hospitals or other hospitals. Further research is needed to identify whether this disparity is due to a lower rate of opioid prescribing or a lower rate of prescription filling.
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Affiliation(s)
- Amy E Lawrence
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Deena J Chisolm
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Sharon K Wrona
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
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Rancan A, Andreetta M, Gaio P, Cananzi M, Rossoni R, La Pergola E, Fascetti Leon F, Gamba P. "Rendezvous" Procedure in Children with Cholecysto-Choledocholithiasis. J Laparoendosc Adv Surg Tech A 2019; 29:1081-1084. [PMID: 31237499 DOI: 10.1089/lap.2018.0696] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cholecysto-choledocolithiasis is a rare entity in children and its management is still challenging and controversial. The laparoendoscopic rendezvous (LERV) procedure, consisting of laparoscopic cholecystectomy and simultaneous endoscopic retrograde cholangiopancreatography for the management of symptomatic choledocholithiasis is well described in adult patients. However, in the literature, few reports about its application in the pediatric population have been recorded. Aim of the Study: The aim of the present study is to report our first successful cases of symptomatic cholecysto-choledocholithiasis LERV treatment. Methods: Two girls suffering of hemolytic disease presented to our third referral center with acute abdominal pain due to cholecysto-choledocholithiasis. Preoperative, perioperative, and postoperative data were retrospectively reviewed. Results: Surgery was performed without complications. The girls were dismissed once re-alimentation and re-canalization were achieved and had no other episodes of biliary cholic. Reported advantages of LERV include: a shorter in-hospital stay, a reduction in the number of procedures and anesthesia, and a reduced overall risk of complications. Conclusions: The promising result with our 2 cases suggest that, when performed in highly specialized centers, LERV is a safe procedure, which leads to considerable benefits, despite logistic and organizational difficulties.
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Affiliation(s)
- Alessandra Rancan
- 1Pediatric Surgery Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Marina Andreetta
- 1Pediatric Surgery Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Paola Gaio
- 2Pediatric Gastroenterology Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Mara Cananzi
- 2Pediatric Gastroenterology Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Rossana Rossoni
- 3Surgical Endoscopy Unit, Azienda Ospedaliera di Padova, Padova, Italy
| | - Enrico La Pergola
- 1Pediatric Surgery Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Francesco Fascetti Leon
- 1Pediatric Surgery Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Piergiorgio Gamba
- 1Pediatric Surgery Unit, Department of Women's and Children's Health, University of Padua, Padova, Italy
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Abstract
OBJECTIVE We reviewed medical records and conducted a nationwide survey to characterize the clinical features and determine the prevalence of biliary tract disease in girls and women with Rett syndrome (RTT). METHODS Sixty-two individuals with RTT and biliary tract disease were identified from the membership of Rett Syndrome Organization and patient files of the principal investigator. Medical records of 46 individuals were reviewed for presenting features, diagnostic tests, and treatment outcomes of biliary tract disease. We designed a questionnaire that probed the frequency of risk factors and treatment outcomes of biliary tract disease in RTT. The questionnaire was completed by 271 parents whose daughters met the clinical criteria for RTT and/or had MECP2 mutations and participated in the Natural History of Rett Syndrome Study. RESULTS Presenting symptoms identified by record review included abdominal pain (94%), irritability (88%), weight loss (64%), and vomiting (52%). Biliary dyskinesia, cholecystitis, and cholelithiasis were identified in 90%, 77%, and 70%, respectively, by cholescintigraphy, surgical pathology, and abdominal ultrasound. The prevalence of biliary tract disease was 4.4% (n = 12) in the RTT cohort. Risk factors included older age (P < 0.001) and a positive family history (P < 0.01). Diagnoses included cholecystitis (n = 5), biliary dyskinesia (n = 6), and cholelithiasis (n = 7). Ten individuals underwent surgery; 7 had resolution of symptoms after surgical intervention. CONCLUSIONS Biliary tract disease is not unique to RTT, but may be under-recognized because of the cognitive impairment of affected individuals. Early diagnostic evaluation and intervention may improve the health and quality of life of individuals affected with RTT and biliary tract disease.
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Adolescent gallstones-need for early intervention in symptomatic idiopathic gallstones. Pediatr Surg Int 2019; 35:569-574. [PMID: 30806765 DOI: 10.1007/s00383-019-04461-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Currently, there is a paucity of the literature describing the natural history of cholelithiasis (CL) and choledocholithiasis (CDL) in adolescent children. This study aims to analyse the changing demographics of paediatric and adolescent gallstones. METHODOLOGY Retrospective review of all children (Age 0-18 years) presenting with symptomatic gallstones over the last 15 years (2002-2017) at a single tertiary institution. Demographics, diagnostic and therapeutic information were collected, with a 5-year median follow-up. Statistics were accomplished by Chi-squared analysis of trend and Student t test. RESULTS AND DISCUSSIONS 188 children were seen with symptomatic CL. In the 0-11-year-old group, there were 13 females and 16 males (0.8: female to male ratio). There were 130 females and 29 males in the 12-18-year-old group (4.5:1 female to male ratio). The mean weight at presentation was 81.78 kg and the median age was 16 years. Idiopathic gallstones were found in 131 patients (82%). 137 required cholecystectomy (86%) and ERCP was required in 32 patients (20%). 48 adolescents (30.2%) with gallstones had an associated CDL, compared to six children (20%). All of the adolescent patients with CDL had idiopathic gallstones. Gallstone pancreatitis was noted in eighteen adolescents (11%) and one child (3%). We analysed the ideal time to operate on adolescent patients with symptomatic gallstones using the relationship between the length of delay from initial diagnosis to definitive management of CDL and incidence of complications. The analysis demonstrated that for every 10 days treatment was delayed, the risk of subsequent presentations with a symptomatic episode was increased by 5% (p = 0.0004). CONCLUSION The current trend of gallstones in adolescent children seems to be a disease primarily of adolescent girls. Symptomatic idiopathic gallstones in adolescents are associated with high rates of common bile duct obstruction and pancreatitis and consequently warrant an early cholecystectomy for all adolescents. LEVEL OF EVIDENCE Level IV Treatment Study.
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Pogorelic Z, Aralica M, Jukic M, Zitko V, Despot R, Juric I. Gallbladder Disease in Children: A 20-year Single-center Experience. Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1535-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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