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Kulaylat AN, Lucas DJ, Chang HL, Derderian SC, Beres AL, Ham PB, Huerta CT, Sulkowski JP, Wakeman D, Englum BR, Gulack BC, Acker SN, Gonzalez KW, Levene TL, Christison-Lagay E, Mansfield SA, Yousef Y, Pennell CP, Russell KW, Rentea RM, Tashiro J, Diesen DL, Alemayehu H, Ricca R, Kelley-Quon L, Rialon KL. Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee. J Pediatr Surg 2024:161678. [PMID: 39227244 DOI: 10.1016/j.jpedsurg.2024.08.018] [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] [Received: 06/21/2024] [Accepted: 08/05/2024] [Indexed: 09/05/2024]
Abstract
INTRODUCTION The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations. METHODS Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management. CONCLUSIONS Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy. LEVEL OF EVIDENCE Level 3-4. TYPE OF STUDY Systematic Review of Level 3-4 Studies.
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Affiliation(s)
- Afif N Kulaylat
- Penn State Children's Hospital, Division of Pediatric Surgery, Hershey, PA, USA.
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center, San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Henry L Chang
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - S Christopher Derderian
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - P Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital of Buffalo, University at Buffalo, Buffalo, NY, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Brian R Englum
- Division of Pediatric Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | | | | | - Emily Christison-Lagay
- Division of Pediatric Surgery, Yale-New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy- Kansas City, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Diana L Diesen
- Division of Pediatric Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Hanna Alemayehu
- Division of Pediatric Surgery, Emory University School of Medicine - Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Robert Ricca
- Division of Pediatric Surgery, University of South Carolina, Greenville, SC, USA
| | | | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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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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Abstract
Nearly 20,000 pediatric patients undergo cholecystectomy annually, and abnormal gallbladder emptying ("biliary dyskinesia") has replaced cholelithiasis as the leading indication for this operation in the USA. Nonetheless, patients with abnormal gallbladder emptying nuclear medicine scans do not uniformly benefit from cholecystectomy. This article reviews the available data on presentation, workup and treatment of patients with abnormally low and high rates of gallbladder emptying.
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Affiliation(s)
- M Coluccio
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 818 Ellicott St, Buffalo, New York, 14203, USA
| | - A J Claffey
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 818 Ellicott St, Buffalo, New York, 14203, USA
| | - D H Rothstein
- Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 818 Ellicott St, Buffalo, New York, 14203, USA; Department of Pediatric Surgery, John R. Oishei Children's Hospital, 818 Ellicott St, Buffalo, New York, 14203, USA.
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Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study. J Pediatr Surg 2019; 54:1118-1122. [PMID: 30885555 PMCID: PMC6822378 DOI: 10.1016/j.jpedsurg.2019.02.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/21/2019] [Indexed: 12/27/2022]
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. STUDY TYPE Case Series, Retrospective Review. LEVEL OF EVIDENCE Level IV.
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Lai SW, Rothenberg SS, Kay SM, Shipman KE, Slater BJ. Outcomes of Laparoscopic Cholecystectomy for Biliary Dyskinesia in Children. J Laparoendosc Adv Surg Tech A 2017; 27:845-850. [DOI: 10.1089/lap.2016.0338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Sarah W. Lai
- Alberta Children's Hospital, Calgary, Alberta, Canada
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Steven S. Rothenberg
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Saundra M. Kay
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Kristin E. Shipman
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Bethany J. Slater
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
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Nakayuenyongsuk W, Choudry H, Yeung KA, Karnsakul W. Decision-making patterns in managing children with suspected biliary dyskinesia. World J Clin Pediatr 2017; 6:124-131. [PMID: 28540197 PMCID: PMC5424281 DOI: 10.5409/wjcp.v6.i2.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/04/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To explore and to analyze the patterns in decision-making by pediatric gastroenterologists in managing a child with a suspected diagnosis of functional gallbladder disorder (FGBD).
METHODS The questionnaire survey included a case history with right upper quadrant pain and was sent to pediatric gastroenterologists worldwide via an internet list server called the PEDGI Bulletin Board.
RESULTS Differences in decision-making among respondents in managing this case were observed at each level of investigations and management. Cholecystokinin-scintigraphy scan (CCK-CS) was the most common investigation followed by an endoscopy. A proton pump inhibitor was most commonly prescribed treating the condition. The majority of respondents considered a referral for a surgical evaluation when CCK-CS showed a decreased gallbladder ejection fraction (GBEF) value with biliary-type pain during CCK injection.
CONCLUSION CCK infusion rate in CCK-CS-CS and GBEF cut-off limits were inconsistent throughout practices. The criteria for a referral to a surgeon were not uniform from one practitioner to another. A multidisciplinary team approach with pediatric gastroenterologists and surgeons is required guide the decision-making managing a child with suspected FGBD.
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Abstract
Cholecystectomy rates for biliary dyskinesia in children are rising in the United States, but not in other countries. Biliary dyskinesia is a validated functional gallbladder disorder in adults, requiring biliary colic in the diagnosis. In contrast, most studies in children require upper abdominal pain, absent gallstones on ultrasound, and an abnormal gallbladder ejection fraction (GBEF) on cholecystokinin-stimulated cholescintigraphy for diagnosis. We aimed to systematically review existing literature in biliary dyskinesia in children, determine the validity and reliability of diagnostic criteria, GBEF, and to assess outcomes following cholecystectomy. We performed a systematic review following the PRISMA checklist and searched 7 databases including PubMed, Scopus, Embase, Ovid, MEDLINE, ProQuest, Web of Science, and the Cochrane library. Bibliographies of articles were screened for additional studies. Our search terms yielded 916 articles of which 28 were included. Three articles were manually added from searched references. We reviewed 31 peer-reviewed publications, all retrospective chart reviews. There was heterogeneity in diagnostic criteria and GBEF values. Outcomes after laparoscopic cholecystectomy varied from 34% to 100% success, and there was no consensus concerning factors influencing outcomes. The observational, retrospective study designs that comprised our review limited interpretation of safety and efficacy of the investigations and treatment in biliary dyskinesia in children. Symptoms of biliary dyskinesia overlapped with functional dyspepsia. There is a need for consensus on symptoms defining biliary dyskinesia, validation of testing required for diagnosis of biliary dyskinesia, and randomized controlled trials comparing medical versus surgical management in children with upper abdominal pain.
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Srinath AI, Youk AO, Bielefeldt K. Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin? Dig Dis Sci 2014; 59:1307-15. [PMID: 24715545 PMCID: PMC4113830 DOI: 10.1007/s10620-014-3126-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/18/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis. AIMS We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH). METHODS Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh. RESULTS Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy. CONCLUSIONS A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.
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Affiliation(s)
- Arvind I. Srinath
- Division of Pediatric Gastroenterology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Ada O. Youk
- Department of Biostatistics, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Klaus Bielefeldt
- Division of Gastroenterology, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Abstract
Biliary dyskinesia (BD) is a diagnosis that is being made increasingly in children. It is defined by abdominal pain thought to be biliary in nature based on location and character; a completely normal gallbladder on imaging tests, typically ultrasound; and decreased gallbladder contraction in response to a pharmacological stimulus. Unlike other functional gastrointestinal disorders (FGIDs) that are treated with medications, behavioral therapy, and/or dietary modification, current clinical practice has accepted cholecystectomy as the treatment of choice for BD, which now accounts for up to 50% of cholecystectomies in children. Although well-designed trials are missing, accumulating evidence argues against such an approach. First, BD is by definition a benign disorder without risk of truly relevant complications. Second, despite reportedly high rates of satisfaction with postoperative outcomes, most children continue to experience symptoms. Lastly, limited long-term studies have demonstrated comparable benefit of operative and conservative therapy. To summarize, BD should be seen as a more localized manifestation of functional abdominal pain, which may improve over time independent of the type of therapy chosen. Despite the widespread adoption of minimally invasive surgery in pediatrics, a different risk-benefit ratio favors conservative treatment for this benign disorder.
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Walker SK, Maki AC, Cannon RM, Foley DS, Wilson KM, Galganski LA, Wiesenauer CA, Bond SJ. Etiology and incidence of pediatric gallbladder disease. Surgery 2013; 154:927-31; discussion 931-3. [DOI: 10.1016/j.surg.2013.04.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/19/2013] [Indexed: 12/29/2022]
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