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PEDIATRICS Vol. 105 No. 6 June 2000, pp. 1250-1253
From the Michael E. DeBakey * Department of Surgery and the
Department of Pediatrics, Baylor College of Medicine, Houston,
Texas.
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ABSTRACT |
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Purpose. The purpose of this study was to determine indications for gallbladder surgery and risk factors for urgent surgery.
Methods. We reviewed all patients <19 years old, who underwent cholecystectomy between 1980 and 1996.
Results. There were 128 patients (mean age: 10 years). Fifty-two patients had an underlying hematologic disorder, 47 had another medical disorder, and 29 had no preexisting illness or identifiable risk factor for gallstone disease. Twenty-five percent (32/128) of cholecystectomies were performed urgently. Postoperative complications developed in 5 of 32 patients (16%) who underwent emergency surgery and 6 of 96 patients (6%) who underwent elective surgery. There were 3 deaths, all occurring in patients undergoing emergency cholecystectomy (odds ratio: 23). Furthermore, all who died had congenital heart disease (odds ratio: 183), making congenital heart disease an independent risk factor for gallstone-related mortality.
Conclusions. Cholecystectomy is recommended when medically possible for children with underlying medical diseases. Patients with medical disorders that make them a high surgical risk can be followed clinically, realizing that if urgent surgery is necessary, the morbidity is relatively high. Those children with congenital heart disease and gallstones are at a prohibitively high risk for death after urgent cholecystectomy. For these patients, the risk of an elective cholecystectomy may be acceptable when weighed against the high risk of complications from their gallstones. Key words: pediatric, gallbladder, cholecystectomy.
Cholecystectomy is a relatively uncommon operation in
children. We have observed that the cause of pediatric gallbladder
disease is changing and that a disproportionately higher number of
emergency cholecystectomies are performed in children compared with
adults.
The purpose of this article is to review all cases of pediatric
cholecystectomy at a single institution to determine indications for
gallbladder surgery and risk factors for urgent surgery.
The medical records of all children 18 years old and younger,
who underwent surgery for cholelithiasis, cholecystitis, and/or choledocholithiasis at Texas Children's Hospital between 1980 and 1996 were reviewed. This chart review was conducted in accordance with
institutional review board approval to protect patient confidentiality.
Cholecystectomy was performed in 128 patients. The mean age was 10 years old (range: 2 months to 18 years old). Seven (6%) patients in
this series were 12 months old or younger. There were 59 boys (47%)
and 69 girls (53%). The cause for gallbladder disease was identified
as hemolytic disease in 52 patients (41%; Table
1). Other medical disorders or risk
factors for gallstone disease were identified in 47 patients and
included cystic fibrosis (n = 6), congenital heart
disease (n = 6), chronic use of total parenteral nutrition (n = 4), previous ileal resection
(n = 2), morbid obesity (n = 8), use of
total parenteral nutrition in premature infants (n = 6), and family history of gallstone disease (n = 3).
Twelve other patients had other serious medical illnesses that may have contributed to the development of biliary stasis and cholecystitis. Twenty-nine patients (22%) had no preexisting illness or identifiable risk factor. There were no instances in which cholecystectomy was
performed for biliary dyskinesia.
TABLE 1
METHODS
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RESULTS
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Hematologic Disorders Associated With Gallbladder
Disease
Operative procedures performed include laparoscopic cholecystectomy (n = 19), open cholecystectomy (n = 89), open cholecystectomy with common bile duct exploration (n = 16), open cholecystectomy with common bile duct exploration and choledochoenterostomy (n = 3), and cholecystostomy followed by open cholecystectomy (n = 1).
Thirty-two cholecystectomies (25%) were performed urgently. The incidence increased from 11% between 1980 and 1984 to 29% between 1990 and 1996 (P = .09). The indications for urgent surgery were acute cholecystitis (n = 18), choledocholithiasis (n = 8), cholangitis (n = 3), gallstone pancreatitis (n = 2), and spherocytosis crisis (n = 1).
There were 6 cases (5%) of acalculous cholecystitis, and in each case, the onset was acute and surgery was performed urgently. Age, gender, race, and gallstone cause were not risk factors for emergency surgery (Table 2). Patients requiring urgent surgery were more likely to undergo a more complicated procedure (n = 15 vs n = 4), such as common bile duct exploration or biliary-enteric anastomosis (P < .001). In addition, patients undergoing an urgent procedure had a longer operative time (135 ± 14 minutes vs 100 ± 7 minutes; P < .05) and required more postoperative analgesia (1.8 ± .5 mg/kg vs 1.1 ± .3 mg/kg of morphine; P = not significant). They also took longer to resume oral feedings (2.3 ± .4 days vs 1.1 ± 0.1 days; P < .01) and had a longer postoperative hospital stay than patients undergoing elective surgery (6.5 ± .9 days vs 5.4 ± .8 days; P = not significant). There was less blood loss in the urgent group compared with elective; however, this was not statistically significant (1.28 ± 1.20 mL/kg vs 1.71 ± 3.09 mL/kg; P = .55).
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There were 11 complications in the 128 procedures performed (9%), 6/96 (6%) in the elective group and 5/32 (16%) in the emergency group (P < .009; Table 3). There were 3 deaths for an overall mortality of 2%. These deaths all occurred after emergency surgery (odds ratio: 23) and all 3 patients had underlying congenital heart disease (odds ratio: 183).
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DISCUSSION |
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Unlike adults who usually undergo cholecystectomy for cholesterol cholelithiasis and have no other medical conditions, pediatric cholecystectomies were historically performed in patients with an underlying medical illness. Pediatric cholelithiasis was viewed as a disease of prematurity, usually related to the use of total parenteral nutrition, or in adolescence, usually related to hemolytic disease. In our series, however, only 41% of children had hematologic disease, and 23% had no underlying illness or risk factor. This observation is in keeping with other current reports that have suggested a higher incidence of nonhemolytic cholelithiasis in recent years.1
The number of pediatric cholecystectomies being performed at Texas Children's Hospital has increased over the past 17 years. Indeed, this rise has been going on since 1960. In a 20-year review published from our institution in 1984, only 36 cholecystectomies were performed. This may be because patients with sickle cell disease and abdominal pain were often diagnosed as having a sickle cell crisis when in fact their symptoms were caused by biliary colic.2 Pediatricians, recognizing that the hemolytic disorders are risk factors for cholelithiasis, now screen and follow this group of patients. Consequently, the number of operations in this group has remained relatively constant at Texas Children's Hospital since 1980. Most of the recent rise in gallbladder surgery has occurred in children with an underlying nonhematologic illness or with other known risk factors for gallstone disease. This may be attributed to the routine use of ultrasound in the evaluation of abdominal pain since the early 1980s.
In this series, 7 patients (6%) were 12 months of age or younger. Cholelithiasis is certainly well-described in the infant population. Halpern and colleagues3 analyzed bile aspirated from the gallbladder and found that infants had a shorter nucleation time and a higher cholesterol saturation index than did children. This may explain the increased tendency of infants to produce sludge and gallstones during total parenteral nutrition. Total parenteral nutrition was believed to be the cause of gallbladder disease in 10 of our cases (8%). Six of these patients were infants. Urgent surgery was necessary in only 1 case. Most infants with cholelithiasis had spontaneous resolution of their gallstones and did not require any intervention. This observation has been made by other investigators. Debray et al4 followed 40 infants <1 year of age over a 17-year period. In 6 infants, gallstones were an incidental finding. Under conservative management, no complications were observed in 3 infants and spontaneous resolution occurred in 2 others. In the 34 other infants, there were stones in the biliary tree. Spontaneous resolution occurred in 13 cases. Therefore, it is recommended to perform surgery only in the event of a stone-related complication.
Patients with cystic fibrosis may present with symptoms related to cholelithiasis, inspissated bile or biliary dyskinesia. Gallstones related to cystic fibrosis often present in a delayed fashion because symptoms are masked by other related conditions like malabsorption and pulmonary disease.5 This is in keeping with our findings where 6 children (5%) having gallbladder surgery had cystic fibrosis and one half of these had symptoms for over a year.
In addition to the fact that the cause of pediatric gallstones has changed, we also observed a change in the incidence of urgent gallbladder surgery. Between 1990 and 1996, 30% of gallbladder surgery was performed urgently, compared with 22% from 1985 to 1989 and 11% from 1980 to 1984. Overall, urgent surgery was required in 25% of patients. The indications included acute cholecystitis, choledocholithiasis, cholangitis, gallstone pancreatitis, and spherocytosis crisis. Three cases of acute cholecystitis, 3 cases of choledocholithiasis, and 4 cases of gallstone pancreatitis were successfully treated medically and subsequently underwent elective cholecystectomy. Most complications of gallstone disease required urgent surgery except for gallstone pancreatitis, which is usually treated with endoscopic retrograde cholangiopancreatography. The incidence of urgent cholecystectomy in children with underlying hematologic disease has remained relatively stable at 25% over the past 17 years. In the subset of patients with no preexisting illness or risk factor, urgent cholecystectomy has increased from 0% to 20%. However, this is not significant given the small number of cases. Urgent surgery in children with an underlying medical illness or risk factor has increased significantly from 0% to 30%. The rise in number of cholecystectomies performed in children without hematologic disorders may stem from improved medical care for children with severe medical illness including cystic fibrosis, prematurity, and congenital heart disease who are now surviving long enough to develop complications of biliary tract disease.
The overall complication rate was 9%. It was more than twice as high in urgent surgery than elective (16% vs 6%). In this series, children who underwent urgent procedures were less likely to have cholecystectomy alone and more likely to have a complex operation, such as common bile duct exploration or choledochoenterostomy. In addition, this group of patients had an operative time that was prolonged by over 30 minutes, required more narcotic analgesic, had to wait an extra day before starting to eat, and stayed in the hospital longer.
The overall mortality rate was 2%. All 3 deaths occurred in children who underwent urgent surgery, which is statistically significant with an odds ratio of 23. There were 6 children (5%) with congenital heart disease who underwent cholecystectomy during the study. Four had urgent surgery and 3 of these died (75%). The first death occurred in a 17-year-old female who had a history of surgery for truncus arteriosus, pulmonary vascular obstructive disease, and an artificial heart valve. She presented with a 2-week history of acute calculus cholecystitis and was treated with a cholecystostomy. She died on postoperative day 1 of multiple system organ failure. The second death was in an 18-year-old boy who had undergone open heart surgery 5 years before for repair of an endocardial cushion defect. He presented with a 4-day history of abdominal pain and was found to have acute cholecystitis, choledocholithiasis, and a gallstone in the appendix causing appendicitis. He underwent open cholecystectomy, common bile duct exploration, and appendectomy. He died on postoperative day 1 of a presumed arrhythmia. The third death was in a 10-month-old infant who had a heart transplant. He developed acalculous cholecystitis and died of multiple system organ failure. The odds ratio for mortality associated with congenital heart disease is 183.
It has been shown that there is an increased risk of biliary complications in both adult and pediatric heart transplant recipients. The prevalence of biliary tract stones in pediatric heart transplant recipients is 15.6%.6 It is postulated that a higher rate of hemolysis, cyclosporine-induced changes in bile metabolism, and azathioprine toxicity may contribute to lithogenesis in this population. It is recommended that transplant candidates have ultrasound screening preoperatively. Patients who have gallstones on pretransplantation evaluation or in whom gallstones develop after transplantation should undergo laparoscopic cholecystectomy at the earliest time in their posttransplantation course (ie, 3 months) regardless of their symptomatic status.7
It seems that children enjoy the same benefits of laparoscopic cholecystectomy as adults. In a recent review, Miltenburg et al8 showed that although pediatric laparoscopic cholecystectomy took longer than open cholecystectomy, it resulted in less postoperative narcotic use and a shorter postoperative stay.
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CONCLUSION |
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Methods
Results
Discussion
Conclusion
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The number of urgent cholecystectomies in the pediatric population has increased in the last decade. This may be attributable to the increased use of ultrasound in the evaluation of abdominal pain. There is a higher morbidity and mortality with urgent surgery compared with elective surgery. Congenital heart disease is associated with emergency cholecystectomy and a 50% mortality rate. Based on this review, it is recommended that infants and children with gallstones undergo cholecystectomy before heart surgery, and infants and children with significant cardiac disease undergo prompt cholecystectomy if gallstones develop. In addition, cholecystectomy is recommended, when medically possible, for children with underlying medical diseases. Patients with medical disorders that make them a high surgical risk can be followed clinically, realizing that if urgent surgery is necessary, the morbidity is relatively high.
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FOOTNOTES |
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Received for publication Jun 15, 1999; accepted Oct 5, 1999.
Reprint requests to (M.L.B.) Department of Pediatric Surgery, Baylor College of Medicine, 1102 Bates, Suite 245, Houston, TX 77030. E-mail: mbrandt{at}bcm.tmc.edu
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