Long-term results of cholecystectomy for biliary dyskinesia: outcomes and resource utilization

Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee

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.

Hypokinetic Biliary Dyskinesia in a Pediatric Patient: A Case Report

The diagnosis of biliary dyskinesia (BD) in pediatric patients lacks uniformity across the literature. BD is among the most common reasons for cholecystectomy in pediatric patients. Even still, diagnostic criteria for this disorder, including symptomatology and gallbladder ejection fraction, as well as the symptomatic relief after cholecystectomy, are inconsistent across the literature for the pediatric population. We share the case of an 18-year-old female patient who presented to our clinic for cholecystectomy for a diagnosis of BD. After 10 months of seeking a diagnosis, an eventual nuclear medicine HIDA scan revealed a biliary ejection fraction of 18%, leading her to our care. The patient underwent robotic-assisted laparoscopic cholecystectomy and tolerated the procedure well, reporting a resolution of symptoms on follow-up. The diagnosis and management of BD are complicated by the combination of vague and varied symptomatology and a lack of definitive, uniform diagnostic criteria in the pediatric population. Variability in diagnostic requirements varies between sources. While some look to the interpretation of gallbladder emptying studies, others rely on surgical outcomes. To further complicate diagnosis, some patients experience symptoms that do not correlate with their gallbladder emptying studies. The controversy extends beyond diagnosis as some studies argue against cholecystectomy as a treatment for BD, as it has been shown to not always resolve symptoms. More research should be conducted to identify and establish more consistent diagnostic criteria for BD in the pediatric population, as well as to study symptomatic improvement following cholecystectomy to establish optimal treatment for these patients. Biliary dyskinesia is a relatively common but rather inconsistent diagnosis in the pediatric population, and attention should be turned toward developing uniform and consistent diagnostic criteria in order to optimally recognize, diagnose, and treat these patients, ensuring a shorter time-to-diagnosis and improved quality of life.

A pediatric surgeon's dilemma: does cholecystectomy improve symptoms of biliary dyskinesia?

BACKGROUND

Biliary dyskinesia (BD) is a well-established gallbladder pathology in adult patients and rates of cholecystectomy for BD continue to rise in the United States. Many pediatric patients with vague abdominal pain of variable duration are evaluated for biliary dyskinesia. It remains unknown which cohort of pediatric patients diagnosed with BD are most likely to have sustained improvement in symptoms following laparoscopic cholecystectomy. We aimed to determine whether cholecystectomy resulted in symptom relief and led to a reduction in the number of medical visits related to gastrointestinal (GI) symptoms after surgery.

METHODS

We performed a multi-institution retrospective review of all children < 18 years of age who underwent laparoscopic cholecystectomy for BD between January 2013 and April 2018 in our hospital system. GI symptoms and clinical visits related to a GI complaint were assessed preoperatively. Patients were followed for 2 years after surgery. At 6 months and 2 years postoperatively, symptoms and the rate of medical visits related to a GI complaint were quantified and compared to the preoperative values.

RESULTS

In total, 45 patients met our inclusion criteria. Of these, 82% of patients were female. The average age was 14 years old (± 2.6) and 56% of patients met the criteria for being overweight or obese. The mean gallbladder ejection fraction was 13% (± 10.8). All patients had abdominal pain, 82% (37/45) presented with nausea, and 51% (23/45) presented with post-prandial pain. Six months postoperatively, 58% of patients experienced resolution of their abdominal pain which decreased to 38% of patients after 2 years. Similarly, 59% had resolution of their nausea at 6 months compared to 43% at 2 years, and 100% had resolution of their post-prandial pain at 6 months compared to 91% at 2 years. The total number of clinical visits related to a GI complaint decreased from 2.6 (± 2.4) preoperatively to 1.0 (± 1.3) within 6 months postoperatively. When followed to 2 years postoperatively, the 6-month rate of clinical visits related to a GI complaint decreased from a mean of 2.6 preoperatively to 0.71 following surgery.

CONCLUSIONS

Following cholecystectomy, we observed a high percentage of durable symptom resolution in those patients with BD who presented with post-prandial pain. Patients with non-food-related abdominal pain, with or without nausea and vomiting, had a lower rate of symptom resolution after surgery and the rate declined with time. For patients without post-prandial pain, evaluation and treatment of alternative sources of pain should be considered prior to surgery. Regardless of their presenting symptoms, patients who underwent surgery for BD had fewer clinical GI-related visits after surgery. However, no specific gallbladder ejection fraction or symptom alone was predictive of a lower rate of clinical visits postoperatively.

Biliary Dyskinesia: Fact or fiction?

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.

Biliary Dyskinesia in Children and Adolescents: A Mini Review

Introduction: While functional gallbladder disorder is a well-recognized and defined condition in adults, its pediatric analog, biliary dyskinesia, lacks uniformity in diagnosis. Yet, biliary dyskinesia is among the most common conditions resulting in cholecystectomy in youth and its frequency continues to rise. The primary aims of the current review were assess the efficacy of cholecystectomy in children diagnosed with biliary dyskinesia and the utility of cholescintigraphy in predicting outcomes. Results: All previous studies assessing outcomes in youth with biliary dyskinesia have been retrospective and therefore of low quality. There is a lack of uniformity in patient selection. Short term follow-up reveals partial response in 63.4-100% with complete resolution in 44.2-100%. Only 4 studies have reported long-term outcomes with complete symptom resolution in 44-60.7%. The published research generally indicates that the gallbladder ejection fraction (GBEF) as determined by cholescintigraphy lacks utility in predicting cholecystectomy outcome utilizing the commonly used cut-off values. There are data suggesting that more extreme cut-off values may improve the predictive value of GBEF. Conclusion: There is a lack of consensus on the symptom profile defining biliary dyskinesia in youth and current literature does not support the use of cholescintigraphy to select patients for cholecystectomy. There is a substantial portion of pediatric patients diagnosed with biliary dyskinesia who do not experience long-term benefit from cholecystectomy. Well-designed prospective studies of surgical outcomes are lacking. Increasing the uniformity in patient selection, including both symptom profiles and cholescintigraphy results, will be key in understanding the utility of cholecystectomy for this condition.