Laparoscopic cholecystectomy for biliary dyskinesia in children: Frequency increasing

doi:10.1016/j.jpedsurg.2012.08.036

Journal of Pediatric Surgery

Volume 48, Issue 8, August 2013, Pages 1716-1721

https://doi.org/10.1016/j.jpedsurg.2012.08.036 Get rights and content

Abstract

Purpose

The treatment of children with biliary dyskinesia (BD) is controversial. As we recently observed an increasing frequency of referrals for BD in our institution the aim of the study was to re-evaluate the long-term outcome in children with BD.

Methods

Children with laparoscopic cholecystectomy (LC) for suspected BD between 8/2006 and 5/2011 were included. A pathologic ejection fraction (EF) was defined as < 35%. The long-term effect of cholecystectomy was assessed via a Likert scale symptom questionnaire.

Results

82 children (median age 13.5 years, mean BMI 25.8) were included. CCK-HIDA scan was pathologic in 74 children (90.2%). Mean EF was 16.4%. Histology revealed chronic cholecystitis in 48 (58.5%) children and was normal in 30 children (36.5%). The frequency of LC for suspected BD increased by a factor of 4.3 in the last 10 years. Long term follow-up showed that only 23/52 children (44.2%) were symptom-free after LC. Patients with chronic inflammation were more likely to have persistent symptoms (p = 0.017). An EF < 15% was associated with a resolution of symptoms (p = 0.031).

Conclusion

The frequency of LC for suspected BD in our institution has increased significantly during recent years. The long-term efficacy in our cohort was only 44.2%. We believe that laparoscopic cholecystectomy is likely helpful in patients with an EF < 15%. However, in children with an EF of 15%–35%, based upon our data, we would highly recommend an appropriately thorough pre-op testing to exclude other gastrointestinal disorders prior to consideration of operative management.

Section snippets

Materials and methods

After approval by the institutional review board at the University of Alabama at Birmingham, all children who underwent laparoscopic cholecystectomy between August 2006 and May 2011 (4.8 years) were screened for having received a cholecystokinin (CCK)-stimulated HIDA scan plus laparoscopic cholecystectomy for suspected BD during this period. Gallbladder ejection fraction on CCK-HIDA scan was considered abnormal if it was less than 35% at the end of 30 min after CCK administration [13]. Results

Results

435 children underwent laparoscopic cholecystectomy (363 with four trocars and 72 via single incision pediatric endosurgery approach (SIPES)) between 8/2006 and 5/2011. A total of 82 children (median age 13.5 years; range 5.1–19.2; 67% girls) with chronic abdominal pain and no gallstones on ultrasound had both a CCK-HIDA scan plus laparoscopic cholecystectomy for suspected BD. These children were further analyzed.

Mean BMI was 25.8 (range 14.6–43.5), median BMI percentile was 93rd percentile and

Discussion

Biliary dyskinesia in children, especially in those with upper abdominal pain, has received more attention in recent years [2]. Its pathogenesis is unknown, but the most widely accepted hypothesis is uncoordinated contractions and relaxations of both the gall bladder and the sphincter of Oddi [15], [16]. The subsequent distension of the gallbladder is believed to lead to inflammation, hypersensitivity, and ultimately, dysfunction.

Previous studies have reported a success rate of 72%–100% for

Conclusion

The frequency of laparoscopic cholecystectomy for suspected BD in our institution has increased significantly during recent years. The corresponding long-term efficacy in our cohort was only 44.2%. We believe that laparoscopic cholecystectomy is likely helpful in patients with an EF < 15%. However, in children with an EF of 15%–35%, based upon our data, we would highly recommend an appropriately thorough pre-op testing to exclude other gastrointestinal disorders prior to consideration of

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Cited by (31)

What is the role of the cholecystokinin stimulated HIDA scan in evaluating abdominal pain in children?
2020, Journal of Pediatric Surgery
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.
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.
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.
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.
Case cohort.
IV.
Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study
2019, Journal of Pediatric Surgery
Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial.
We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes.
Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF < 15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms.
There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD.
Case Series, Retrospective Review.
Level IV.
Long-term results of cholecystectomy for biliary dyskinesia: outcomes and resource utilization
2018, Journal of Surgical Research
The purpose of this study is to describe a cohort of pediatric patients undergoing cholecystectomy for biliary dyskinesia (BD) and characterize postoperative resource utilization.
Single-institution, retrospective chart review of pediatric patients after cholecystectomy for BD was done. Patient demographics and clinical characteristics as well as operative details and postoperative interventions were abstracted. Telephone follow-up was performed to identify persistent symptoms, characterize the patient experience, and quantify postoperative resource utilization.
Forty-nine patients were included. Twenty-two patients (45%) were seen postoperatively by a gastroenterologist, of which, only 32% were known to the gastroenterologist before surgery. Postoperative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, five endoscopic retrograde cholangiopancreatographies (ERCPs), one endoscopic ultrasound, one magnetic resonance cholangiopancreaticogram, and five colonoscopies. Of the patients with additional diagnostic testing postoperatively, one had mild esophagitis, three had sphincter of Oddi dysfunction, and one was suspected to have inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea, or vomiting at an average of 26 mo after operation. Of note, all patients who underwent postoperative ERCP with sphincterotomy reported symptom relief following this procedure.
Relief of symptoms postoperatively in pediatric patients with BD is inconsistent. Postoperative studies, though numerous, are of low diagnostic yield and generate high costs. These findings suggest that the initial diagnostic criteria and treatment algorithm may require revision to better predict symptom improvement after surgery. Improvement seen after ERCP/sphincterotomy is anecdotal but appears to merit further investigation.
Minimally Invasive Hepatobiliary Surgery
2017, Clinics in Perinatology
Two birds, one surgical stone: The first reported case of superior mesenteric artery syndrome secondary to biliary dyskinesia
2016, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
Ultrasonography is usually unrevealing for cholelithiasis or other structural causes. The condition can be confirmed by a HIDA scan with CCK showing a poor gallbladder ejection fraction (<35–40%). [2–5], with Carney et al. showing a PPV of 93% in patients with pain, nausea and an EF <15%.
This is the first reported case of superior mesenteric artery syndrome secondary to biliary dyskinesia. SMA syndrome involves obstruction of the third portion of the duodenum, causing a gastric outlet obstruction due to narrowing of the space between the abdominal aorta and the superior mesenteric artery (SMA). Rapid weight loss has been shown to be a risk factor for this condition. We report a case found in a 14-year old Hispanic developmentally delayed female and review the literature. Our patient presented with a one-month history of abdominal pain, bilious emesis, and weight loss. She was seen at an outside facility where she had two abdominal operations without symptomatic relief. A HIDA scan performed at our facility was consistent with biliary dyskinesia, and an UGIS confirmed a concomitant SMA syndrome. An open cholecystectomy with a side-to-side duodenojejunostomy was performed. Postoperatively, patient continued with gastropareisis, requiring nutritional support via TPN and insertion of a jejunostomy tube. On post operative day 24, patient was discharged home tolerating full feeds. She has since been seen in follow up, and is doing well.
Functional gallbladder disease: Operative trends and short-term outcomes
2016, Surgery (United States)
Due to increasing rates of functional gallbladder disease (FGBD), we used national data to compare rates, patient characteristics, and outcomes of cholecystectomy for FGBD with the more defined diagnosis of biliary colic.
The American College of Surgeons National Surgical Quality Improvement Program was reviewed for elective cholecystectomies from 2005–2013. The proportion of cholecystectomies performed for FGBD was assessed over time using a 2-sided Cochran-Armitage test for trend. Cholecystectomy for FGBD was compared with that for biliary colic using univariate analysis, multivariable logistic, and Cox proportional hazard regressions.
Of 156,322 patients undergoing cholecystectomy, 5,161 (3.3%) had FGBD. FGBD as an indication for cholecystectomy remained stable over time (3.4% in 2006 to 3.2% in 2013, P = .29). Compared with biliary colic, patients with FGBD were more likely <50 years old, non-Hispanic white, female, and had a body mass index <25 (all P < .001), while comorbidities were similar (P > .05). While differences in outcomes were seen on univariate analysis, on multivariable analysis, only duration of stay was significantly less for FGBD than biliary colic. Surgery residents were involved in 61.2% of the biliary colic versus 53.9% of FGBD cases (P < .001).
The rate of FGBD as an indication for cholecystectomy is not increasing overall, but cholecystectomy may be more commonly performed at nonacademic hospitals. While cholecystectomy for FGBD appears safe, the outcomes are comparable to cholecystectomy for biliary colic and thus are not without risk.

View all citing articles on Scopus

^☆: Oral presentation at the IPEG's 21st Annual Congress for Endosurgery in Children, March 6–10, 2012, San Diego, CA.

^☆☆: Disclosure statement: No competing financial interests exist for any of the authors.

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Original ArticleLaparoscopic cholecystectomy for biliary dyskinesia in children: Frequency increasing☆,☆☆

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Conclusion

J Surg Res

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Radiol Clin North Am

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Recurrent abdominal pains: a field survey of 1,000 school children

Arch Dis Child

Biliary dyskinesia: the most common indication for cholecystectomy in children

Surgery

Biliary dyskinesia: a potentially unrecognized cause of abdominal pain in children

Pediatr Surg Int

Biliary dyskinesia: natural history and surgical results

Am Surg

Original Article
Laparoscopic cholecystectomy for biliary dyskinesia in children: Frequency increasing☆,☆☆