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Indian Pediatr 2019;56: 384-386 |
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Gallbladder Disease in Children: A 20-year
Single-center Experience
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Zenon Pogorelic 1,2,
Maja Aralica2,
Miro Jukic1,
Vanda Zitko3,
Ranka Despot3 and
Ivo Juric1,2
From Departments of 1Pediatric Surgery and
3Pediatrics, University Hospital of Split, Spinciceva1;
and 2University of Split, School of Medicine, Soltanska2;
Split, Croatia..
Correspondence to: Zenon Pogorelic, Department of
Pediatric Surgery, Head, University Hospital of Split,
Spinciceva 1, 21 000 Split, Croatia.
Email: [email protected]
Received: July 12, 2018;
Initial review: December 17, 2018;
Accepted: February 21, 2019.
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Objective: Aim of this study was
to examine the changes in incidence of pediatric cholecystectomies.
Methods: Based on a review of hospital-records, children were
divided into two groups regarding year of surgery (Group I: 1998-2007;
Group II: 2008-2017) and their characteristics were compared. Results:
Number of cholecystecomies increased from 11 to 34. Median age increased
from 11 to 15.5 years and mean BMI increased from 19.2 kg/m2 to 23.0
kg/m2. Hereditary spherocytosis decreased from 63.6% to 11.8% (P=0.001)
of indications for cholecystectomy, while proportion of cholesterol
stones increased from 27.3% to 70.6% (P=0.006). Frequency of
laparoscopic cholecystectomy increased from 36.4% to 85.3% (P=0.001).
Duration of hospital stay shortened from 8 to 4 days (P=0.008).
Conclusions: Number of pediatric cholecystectomies has
significantly increased in the last 20 years, as well as average BMI of
the observed population This probably signifies a correlation between
rising obesity rates and increase in frequency of symptomatic
cholelithiasis in children.
Keywords: Association; Cholecystectomy;
Hereditary spherocytosis; Obesity.
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I
n recent years, gallstone disease has been
increasingly diagnosed in the pediatric population and the spectrum of
pediatric biliary tract disease has been changing [1]. Until recently,
the majority of pediatric gallstones were pigmented stones, related to
hemolytic diseases such as hereditary spherocytosis [2,3]. In recent
decades, the incidence of gallstone disease in children has risen,
principally related to the epidemic of pediatric obesity [2,3]. Other
than obesity, improved survival of critically ill neonates who have
received long-term total parenteral nutrition or have underlying
abnormalities resulting in short-gut syndrome is the new factor that may
have led to an increased incidence of cholelithiasis in the pediatric
population [3].
The objective of our study was to document the
apparent increase in frequency of cholecystectomies in children, and to
establish the epidemiological, demographic and clinical characteristics
of children who underwent cholecystectomy.
Methods
The case records of 45 children (12 males) who
underwent cholecystectomy due to cholelithiasis from January 1998 to
December 2017 at the Department of Pediatric Surgery, University
Hospital of Split, were retrospectively reviewed. All patients with
symptomatic cholelithiasis who underwent cholecystectomy younger than 18
years of age were enrolled in the study. Preoperative MR cholangiography
was performed in all of the patients. Intraoperative cholangiogram was
performed only in patients with choledocholithiasis. The patients were
divided into two groups (children who were operated on between 1998 and
2007 and children who underwent surgery between 2008 and 2017) and
compared by demographic and anthropometric data, clinical findings, risk
factors for the disease, indications for surgery, procedure type,
treatment outcomes and complications. The patient data are summarized in
Table I.
TABLE I Demographic and Clinical Characteristics of Children Undergoing Cholecystectomy, Croatia.
|
Variable |
1998-2007 |
2008-2017 |
|
Baseline data |
|
*Age, y |
11 (10, 15) |
15.5 (13, 16) |
|
Male sex
|
2 (18.2) |
10 (29.4) |
|
#height, cm |
144.7 (10.1) |
169.5 (15.3) |
|
#Weight |
42.9 (16.8) |
66.9 (18.7) |
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#BMI, kg/m2
|
19.2 (3) |
23.0 (5.1) |
|
<18.5 |
1 (9.1) |
8 (23.5) |
|
18.5-25 |
8 (72.7) |
11 (32.4) |
|
25-30 |
2 (18.2) |
10 (29.4) |
|
>30 |
0
|
5 (14.7) |
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Main indication for surgery |
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Biliary colic
|
4 (36.4) |
17 (50.0) |
|
Hereditary spherocytosis
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7 (63.6) |
4 (11.8) |
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Acute pancreatitis
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0
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7 (20.6) |
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Acute cholecystitis
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0
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4 (11.8) |
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Obstructive jaundice
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0
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2 (5.9) |
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All data in no. (%) except *median (IQR) and #mean
(SD). All P<0.05 for baseline data except sex difference.
Indications for surgery all P>0.05 except hereditary
spherocytosis (P<0.001). |
Statistical analysis: The data were analyzed
using the Microsoft Excel for Windows Version 11.0 (Microsoft
Corporation) and SPSS 19.0 (IBM Corp, Armonk, NY) software programs.
Differences in median values of quantitative variables between the
groups of patients were tested with Mann-Whitney U test. The Chi-square
test was used for the statistical analysis of categorical data. All
values of P<0.05 were considered to indicate statistical
significance.
Results
Out of 45 cholecystectomies, 11 (24.4%) were
conducted in the first half of the study period (1998-2007) and 34
(75.6%) were conducted in the following 10 years (2008-2017), resulting
in a 3.1-fold increase in the incidence of cholecystectomies (P=0.002).
In both groups patients were predominantly female (81.8% vs
70.6%). The median age was 11 (range 6-17) years in the period
1998-2007, with an increase to 15.5 (range 7-17) years in the period
2008-2017 (P=0.001).
The median body weight of children in the first group
was 42.9 (IQR 27.25, 54.75) kg, while it was 66.9 (IQR 55, 79) kg in the
second group (P=0.004). In the first group the body weight of
only 3 (27.3%) children was above the 90 th
percentile, while there were 14 (41.2%) such children in the second
group, with 6 (17.6%) children above the 97th
percentile (P=0.02). The median BMI of children in the first
group was 19.2 kg/m2, with
no obese children. In the second group, the average BMI was 23.0 kg/m2,
with 5 (14.7%) obese children (P=0.012).
The most common indication for cholecystectomy in the
first 10-year period was hereditary spherocytosis (63.6%), while biliary
colic (50.0%) was main indication in the second 10-year period, followed
by acute pancreatitis (20.6%), thus moving hereditary spherocytosis to
the third place (11.8%).
The results of spectrophotometric analysis of
gallstones removed during the first observed period showed a
significantly greater proportion of pigment stones (63.6%), whereas in
the second observed period the majority of gallstones were cholesterol
stones (70.6%) (P=0.006) (Table II).
TABLE II Management and Outcome in Children Undergoing Cholecystectomy in Croatia.
|
Variable |
1998-2007 |
2008-2017 |
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*Laparoscopic surgery, n( %) |
4 (36.4) |
29 (85.3) |
|
Procedures, n( %) |
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Intraoperative cholangiogram |
2 (18.2) |
3 (8.8) |
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Complications, n( %) |
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Bile duct injury |
0 (0) |
1 (2.9) |
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Hospitalization (median, IQR) |
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#Hospitalization, d |
8 (2, 11) |
4 (2, 5) |
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Laparoscopic procedure |
4 (2, 5.5) |
3 (2, 5) |
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Open procedure |
12 (2, 13) |
10 (6, 12) |
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#Type of gallstone, n( %) |
|
Pigment |
7 (63.6) |
5 (14.7) |
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Cholesterol |
3 (27.3) |
24 (70.6) |
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Mixed |
1 (9.1) |
5 (14.7) |
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Histopathology report, n( %) |
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Normal |
4 (36.4) |
3 (8.8) |
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Acute cholecystitis |
0 (0) |
4 (11.8) |
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Chronic cholecystitis |
7 (63.6) |
27 (79.4) |
|
*P<0.001; #P<0.05. |
Discussion
Cholelithiasis in children used to be a rarity, but
we have found that that is no longer the case: in our study there was a
three-fold increase in the number of children who underwent
cholecystectomy in the last 10 years compared to the previous 10-year
period, thus affirming our hypothesis. The age median of children in our
study has increased, while female sex has consistently prevailed in both
observed periods. The median BMI of the observed children has increased
in the last two decades, providing a significant between-group
difference, with an even more significant proportion of children falling
into the obese category. Spectrophotometric analysis of gallstones found
in observed children’s gallbladders revealed that cholesterol stones,
which have been a rarity in the first observed period, have increased to
a vast majority in the more recent decade.
Retrospective character is the main limitation of
this study, although we have implemented multiple plausibility checks
and cross validations in our data collection tool. Also, there is a
relatively small number of patients included in the study, so further
studies are needed to analyze the same parameters on a larger sample.
The increase in the incidence of cholecystectomies in
the pediatric population was already recorded in multiple studies
carried out in the last three decades [2,6,7]. A suggestion was found in
literature that the reason for such a rise could lie in the increasing
use of abdominal ultrasound, with a consequent increase in the ability
to identify gallstones and establish a diagnosis of cholelithiasis
[6,8]. Some authors speculated that the most likely cause for this
condition lied in the increase of average BMI of children with
gallstones based on its increase in the general pediatric population
[2,5,9-10]. In an attempt to additionally correlate excessive body mass
with the increased incidence of cholelithiasis, the composition of
gallstones found in observed children’s gallbladders was compared to
other studies, in which pigment stones were found to represent a vast
majority [11,12]. However, these studies were conducted in the years
accordant to the first period of our study, thus yielding results
consistent with our findings in the said period. The prevalence of
hereditary spherocytosis, and consequently, its proportion among the
indications for cholecystectomy, strongly depends on geography, which
makes it inappropriate for comparison [2,4-5,7,10]. However, the trend
of decrease in the share of hereditary spherocytosis among the
indications for cholecystectomy is consistent with the findings in many
other published studies [6,13-15]. Children who do not suffer from
haemolysis, and therefore, most likely do not have pigment but
cholesterol gallstones, have a significantly higher BMI [10]. This
relates high BMI to cholesterol stones, showing that the average BMI of
children who underwent cholecystectomy probably increased on account of
children who do not have a haemolytic anaemia, which fits the changes of
the share of hereditary spherocytosis among the indications for the
procedure.
In conclusion, this study suggests an association
between rising obesity rates in the pediatric population and the
increase in frequency of symptomatic cholelithiasis in children. If this
hypothesis is proven by larger epidermiological studies, it would
provide an impetus to efforts to prevent this risk factor with lifestyle
changes.
Contributors: ZP: concepted and designed the
study, analyzed data, supervised and revised manuscript critically for
important intellectual content; MA: collected the data, helped in data
analysis, performed literature review and drafted the manuscript; MJ:
drafted the manuscript; VZ: collected the data and revised manuscript
critically; RD: collected the data and revised manuscript critically.
Funding: None; Competing interest: None
stated.
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