Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study

Abstract

Introduction: 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. Methods: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. Results: 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. Conclusion: 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.

Biliary Dyskinesia in Children and Adolescents: A Mini Review

“…In bivariate analysis, previous evaluation and referral from a gastroenterologist was shown to have a positive effect on outcome, adding another layer of patient selection (16). In this study, psychologic co-morbidity was shown to have a negative effect on patient outcomes (16). This is similar to what has been reported with children and adolescents with functional dyspepsia and irritable bowel syndrome (43).…”

“…There are no standardized pediatric criteria for diagnosing biliary dyskinesia so symptomatic diagnosis and the degree of reliance on tests such as cholescintigraphy are at the discretion of individual clinicians. In bivariate analysis, previous evaluation and referral from a gastroenterologist was shown to have a positive effect on outcome, adding another layer of patient selection (16). In this study, psychologic co-morbidity was shown to have a negative effect on patient outcomes (16).…”

“…Also at odds with Rome criteria, 61% reported daily pain (15). An additional 1,178 pediatric patients have been reported in the literature since the previous systematic review and report similar variability (14,(16)(17)(18). In the largest of these studies, a recent multicenter study involving 16 institutions and 678 patients, Cairo et al reported RUQ pain in 76.7% and postprandial pain in 71.4% of pediatric patients diagnosed with biliary dyskinesia (16).…”

“…A more technical issue is that there is wide variety in the protocols employed for cholescintigraphy utilized to assess gallbladder emptying, as well as variability in defining normal cut-off values, as noted in the review of literature above. These issues likely lead to varying results from center to center (16). There also are patient-specific issues which may affect gallbladder emptying, including associated diseases and concomitant medications which are not always considered in interpreting results of cholescintigraphy.…”

Diseases of the gallbladder in children — modern view of pediatric surgeon (systematic review)

“…По-прежнему ведутся дискуссии о выборе рационального лечебно-диагностического подхода к этим пациентам. Некоторые хирурги предлагают ограничивать показания к хирургическому лечению детей с билиарной дискинезией, в то время как другие склоняются к ранней операции, чтобы своевременно отсеять пациентов с другими заболеваниями [11]. Не существует надежного предоперационного предиктора того, что после холецистэктомии, выполненной по поводу дискинезии желчевыводящих путей, произойдет клиническое улучшение, поэтому важно до операции информировать семью ребенка, что абдоминальные симптомы могут не исчезнуть после удаления желчного пузыря.…”