Pediatric obesity and gallstone disease

Who should perform pediatric laparoscopic cholecystectomies? A systematic review of the literature

Laparoscopic cholecystectomy (LC) is an increasingly common operation in the pediatric population, although numbers remain significantly lower than in adults. Currently, this operation is performed by both adult and pediatric surgeons and there is no consensus as to whether specialist low-volume or adult high-volume surgeons should be performing this operation. A literature search was performed to compare the outcomes following pediatric LC when performed by adult or pediatric surgeons. 19,993 patients were included in this analysis. Overall, post-operative complications were reduced when LC was performed by high-volume adult surgeons, along with reduced length of stay and associated cost. Overall morbidity following LC in children is comparable to adults. When performed by higher volume adult surgeons, there was a statically significant reduction in post-operative complications and re-admission rates. Morbidity was also reduced in patients with simple cholelithiasis. Initial results show that in pediatric patients presenting with cholelithiasis, LC performed by a high-volume adult general surgeon is safer. In more complex children with needs from other specialist pediatricians, surgery performed by a pediatric surgeon is recommended. Further research with direct comparisons is still required.

What is the disease burden from childhood and adolescent obesity?: a narrative review

The prevalence of childhood and adolescent obesity has increased and exacerbated during the coronavirus disease 2019 pandemic, both in Korea and globally. Childhood and adolescent obesity poses significant risks for premature morbidity and mortality. The development of serious comorbidities depends not only on the duration of obesity but also on the age of onset. Obesity in children and adolescents affects almost all organ systems, including the endocrine, cardiovascular, gastrointestinal, reproductive, nervous, and immune systems. Obesity in children and adolescents affects growth, cognitive function, and psychosocial interactions during development, in addition to aggravating known adult comorbidities such as type 2 diabetes mellitus, hypertension, dyslipidemia, nonalcoholic fatty liver disease, obstructive sleep apnea, and cancer. Childhood and adolescent obesity are highly associated with increased cardiometabolic risk factors and prevalence of metabolic syndrome. The risk of cardiovascular and metabolic diseases in later life can be considerably decreased by even a small weight loss before the onset of puberty. Childhood and adolescent obesity is a disease that requires treatment and is associated with many comorbidities and disease burdens. Therefore, early detection and therapeutic intervention are crucial.

Follow-up study of gallbladder stones in 44 children

BACKGROUND

Cholesterol stones affect a certain subpopulation of children. Concerns have been raised on the impact of gallbladder surgery on the growth of children and adolescents.

AIM

To study the population characteristics, clinical features, treatment, and prognosis of gallstones in children.

METHODS

The clinical data of 44 children with gallstones admitted to The First Affiliated Hospital of Naval Medical University from August 2009 to August 2021 were collected, the children were followed up by telephone to monitor their prognoses. The follow-up ended in August 2023. The shortest follow-up time was 2 years and 6 months, whereas the longest was 13 years and 11 months. The population characteristics, general clinical characteristics, and treatments were retrospectively analyzed. The children were divided according to whether they underwent surgical gallbladder removal into an operation group (n = 28) and a non-operation group (n = 16), The effects of surgical gallbladder resection on the growth and development of children were analyzed.

RESULTS

The male-female ratio in the population was 6:5 and 84.09% of the children had onset in adolescence. Furthermore, 29.55% of the children were overweight or obese. The study identified 26 cases with metabolic abnormalities, 9 with hemolytic anemia, and 4 with choledochal cyst. Of the population, 68.18% had recurrent symptomatic cholecystolithiasis. Surgical treatment accounted for 63.64%, with laparoscopic cholecystectomy accounting for 71.43% of surgical treatment. No significant differences were observed in symptoms and complications between the surgery and non-surgery groups. Furthermore, no significant differences were found between the two groups in the attainment of genetic height target and the rightward shift of height curve during follow-up.

CONCLUSION

The sex characteristics of gallstones in children were not observed. Most gallstones occurred in adolescents and rarely in young children. A considerable proportion of children have inborn causes, which are often concurrent with metabolic abnormalities and hemolytic anemia. Most children had recurrent symptomatic gallstones. Surgical treatment, especially laparoscopic cholecystectomy, is still the main treatment for gallstones in children. Surgical treatment did not affect the growth and development of children who underwent gallstone removal.

Index admission cholecystectomy for biliary acute pancreatitis or choledocholithiasis reduces 30-day readmission rates in children

BACKGROUND

Adult patients with biliary acute pancreatitis (BAP) or choledocholithiasis who do not undergo cholecystectomy on index admission have worse outcomes. Given the paucity of data on the impact of cholecystectomy during index hospitalization in children, we examined readmission rates among pediatric patients with BAP or choledocholithiasis who underwent index cholecystectomy versus those who did not.

METHODS

Retrospective study of children (< 18 years old) admitted with BAP, without infection or necrosis (ICD-10 K85.10), or choledocholithiasis (K80.3x-K80.7x) using the 2018 National Readmission Database (NRD). Exclusion criteria were necrotizing pancreatitis with or without infected necrosis and death during index admission. Multivariable logistic regression was performed to identify factors associated with 30-day readmission.

RESULTS

In 2018, 1122 children were admitted for index BAP (n = 377, 33.6%) or choledocholithiasis (n = 745, 66.4%). Mean age at admission was 13 (SD 4.2) years; most patients were female (n = 792, 70.6%). Index cholecystectomy was performed in 663 (59.1%) of cases. Thirty-day readmission rate was 10.9% in patients who underwent cholecystectomy during that index admission and 48.8% in those who did not (p < 0.001). In multivariable analysis, patients who underwent index cholecystectomy had lower odds of 30-day readmission than those who did not (OR 0.16, 95% CI 0.11-0.24, p < 0.001).

CONCLUSIONS

Index cholecystectomy was performed in only 59% of pediatric patients admitted with BAP or choledocholithiasis but was associated with 84% decreased odds of readmission within 30 days. Current guidelines should be updated to reflect these findings, and future studies should evaluate barriers to index cholecystectomy.

Case Series of Endoscopic Papillary Balloon Dilation for Children with Common Bile Duct Stones and a Review of the Literature

Background: Endoscopic sphincterotomy (EST) has been employed for the endoscopic treatment of common bile duct stones (CBDSs) and has been reported to have a high success rate for stone removal. However, EST is associated with a risk of bleeding, perforation, and sphincter of Oddi function disruption. To avoid these risks, endoscopic papillary balloon dilation (EPBD) is an option for CBDS. Sphincter of Oddi function preservation decreases long-term biliary infection and gallstone recurrence. EPBD may have advantages in children who require a long follow up. However, there have been few reports on pediatric cases, particularly in infants. Methods: From September 2017 to December 2023, we performed EPBD for four pediatric CBDSs. The patients were aged from 5 months to 8 years, including two infants aged 5 and 6 months. Furthermore, we reviewed the stone removal rate and complications of 545 ESTs performed at high-volume centers and 13 EPBD-reported cases in children with CBDSs. Results: CBDSs of all patients who underwent EPBD in our institution were successfully removed. No bleeding or perforation was noted; pancreatitis was observed in three patients. In an analysis of 545 ESTs in children, the stone removal rate was high, ranging from 83% to 100% (mean 96%). The incidence of pancreatitis was 0-9.6% (mean 4.4%), and the grade of pancreatitis was almost mild. The bleeding frequency was 1.3-5.4% (mean 2.7%). With regards to the grade of bleeding, seven cases were mild (64%) and four were moderate (36%). Compared with adults who underwent EST, the frequencies of pancreatitis and bleeding were almost equal in children; however, in children, once bleeding occurs, it has a higher risk of leading to blood transfusion. Stone removal via EPBD in children has a 100% success rate. Pancreatitis was responsible for all complications were related; its frequency was 46% (6/13 patients, including five mild cases and one moderate case), which is higher than that of EST and adult cases who underwent EPBD. In most children with pancreatitis, pancreatic enzyme levels returned to normal within 2-3 days following EPBD, and no severe cases caused by EPBD were reported. Conclusions: CBDS removal via EPBD in children has a high success rate with very low risk of bleeding and perforation. Although pancreatitis frequently occurs, most cases are mild. Sphincter of Oddi function preservation via EPBD is expected to prevent long-term stone recurrence and biliary tract infection, and EPBD is considered to be an effective method for CBDS removal in children.

Poor Motor Competence Affects Functional Capacities and Healthcare in Children and Adolescents with Obesity

BACKGROUND

From a young age, children learn different motor skills known as fundamental motor skills. The acquisition of these skills is crucial for the future development of context-tailored actions that could improve adherence to physical activity (PA) practice. Motor competence and function deficits have been associated with pediatric obesity. We reviewed the literature data regarding motor competence in pediatrics and impaired motor performance in children and adolescents with obesity.

METHODS

We assessed the abstracts of the available literature (n = 110) and reviewed the full texts of potentially relevant articles (n = 65) that were analyzed to provide a critical discussion.

RESULTS

Children and adolescents with obesity show impaired motor performance, executive functions, postural control, and motor coordination. Children's age represents a crucial point in the development of motor skills. Early interventions are crucial to preventing declines in motor proficiency and impacting children's PA and overall fitness levels.

CONCLUSIONS

To involve children, the PA protocol must be fun and tailored in consideration of several aspects, such as clinical picture, level of physical fitness, and motor skills. A supervised adapted exercise program is useful to personalized PA programs from an early pediatric age.

Childhood Obesity: An Updated Review

BACKGROUND

Childhood obesity is an important and serious public health problem worldwide.

OBJECTIVE

This article aims to familiarize physicians with the evaluation, management, and prevention of childhood.

METHODS

A PubMed search was conducted in May, 2021, in Clinical Queries using the key terms "obesity" OR "obese". The search included clinical trials, randomized controlled trials, case-control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to English literature and children. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Most obese children have exogenous obesity characterized by a growth rate for height above the 50th percentile, normal intelligence, normal genitalia, and lack of historical or physical evidence of an endocrine abnormality or a congenital syndrome. Obese children are at risk for dyslipidemia, hypertension, diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, psychosocial disturbances, impaired quality of life, and shorter life expectancy. The multitude of serious comorbidities necessitates effective treatment modalities. Dietary modification, therapeutic exercise, and behavioral modification are the fundamentals of treatment. Pharmacotherapy and/or bariatric surgery should be considered for obese individuals who do not respond to the above measures and suffer from a serious comorbid condition.

CONCLUSION

Childhood obesity, once established, is often refractory to treatment. Most treatment programs lead to a brief period of weight loss, followed by rapid re-accumulation of the lost weight after the termination of therapy. As such, preventive activity is the key to solving the problem of childhood obesity. Childhood obesity can be prevented by promoting a healthy diet, regular physical activity, and lifestyle modification. Parents should be encouraged to get involved in school and community programs that improve their children's nutritional status and physical activity.

Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of "New Technologies"

BACKGROUND

In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children.

AIMS

This study aims to describe current indications and timing for LC in pediatric patients.

METHODS

Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020-2023.

RESULTS

In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores.

CONCLUSIONS

Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent.

Are children with gallstone disease more overweight? Results of a matched case-control analysis

INTRODUCTION

Gallstone disease (GD) is increasingly common among children, possibly caused by an unhealthy food environment and the associated unhealthy lifestyle. In this study, we investigate the association between body weight and gallstone risk in a cohort of prospectively recruited children with GD.

METHODS

We analysed 188 children with gallstones (50.0% girls, median age 9.8 years) and 376 children without stones who were age- and gender-matched to cases in a ratio of 2:1. Cases were prospectively recruited at three Polish university centres (Warsaw, Katowice and Bialystok). Gallstones were diagnosed by either abdominal sonography or by a history of cholecystectomy. Matched controls without gallstones were selected from 22,412 children taking part in nationally representative Polish health surveys (OLA and OLAF studies) which provided height and weight data for randomly selected pre-school (2.5-6 years) and school aged (7-18 years) children and adolescents.

RESULTS

Analysis of the age- and gender-matched cases and controls demonstrated that patients with GD had significantly higher BMI (P = 0.02) and BMI z-score (P < 0.01) than children without stones. Children with gallstones were more frequently overweight (35.6%, P < 0.01) and obese (12.2%, P < 0.01) than controls (18.4% and 6.7%, respectively). Regression analyses showed that BMI, BMI z-score, overweight and obesity were all associated with increased GD risk (all P < 0.05).

CONCLUSIONS

Overweight and obesity are common in children with cholelithiasis. Given the epidemic of obesity in children we should expect an increasing prevalence of gallstones and stone-related complications in youths and in adults.

Mapping the scientific research on integrated care: a bibliometric and social network analysis

Background

Integrated care (IC) is the cornerstone of the sustainable development of the medical and health system. A thorough examination of the existing scientific literature on IC is essential for assessing the present state of knowledge on this subject. This review seeks to offer an overview of evidence-based knowledge, pinpoint existing knowledge gaps related to IC, and identify areas requiring further research.

Methods

Data were retrieved from the Web of Science Core Collection, from 2010 to 2020. Bibliometrics and social network analysis were used to explore and map the knowledge structure, research hotspots, development status, academic groups and future development trends of IC.

Results

A total of 7,501 articles were obtained. The number of publications on IC was rising in general. Healthcare science services were the most common topics. The United States contributed the highest number of articles. The level of collaboration between countries and between authors was found to be relatively low. The keywords were stratified into four clusters: IC, depression, integrative medicine, and primary health care. In recent years, complementary medicine has become a hotspot and will continue to be a focus.

Conclusion

The study provides a comprehensive analysis of global research hotspots and trends in IC, and highlights the characteristics, challenges, and potential solutions of IC. To address resource fragmentation, collaboration difficulties, insufficient financial incentives, and poor information sharing, international collaboration needs to be strengthened to promote value co-creation and model innovation in IC. The contribution of this study lies in enhancing people's understanding of the current state of IC research, guiding scholars to discover new research perspectives, and providing valuable references for researchers and policymakers in designing and implementing effective IC strategies.

Gallbladder Stones in Pediatric Age: An Emerging Problem: The Risk of Difficult Cholecystectomy and the Importance of a Preoperative Evaluation

The need for cholecystectomy during pediatric age has significantly increased in the last two decades. As biliary pathology increases, the probability of complicated cholecystectomies increases too. The aim of this article is to analyze our experience with difficult laparoscopic pediatric cholecystectomy, focusing on the importance of an accurate pre-operative imaging study. We retrospectively analyzed all patients affected by cholelithiasis who underwent laparoscopic cholecystectomy at the Pediatric Surgery Department of San Camillo Forlanini hospital of Rome and Santa Maria alle Scotte University Hospital of Siena from 2017 to 2022. Demographic data, body mass index (BMI), recovery data, laboratory tests, imaging exams, surgical findings, post operative management and outcome were taken into account. Overall, 34 pediatric patients, with a mean age of 14.1 years (6-18 years) were included, with a mean BMI of 29. All patients underwent abdominal ultrasonography and a liver MRI with cholangiography (cMRI). We identified five cases as "difficult cholecystectomies". Two subtotal cholecystectomies were performed. Cholecystectomy in pediatric surgery can be difficult. The surgeon must be able to find alternative strategies to total cholecystectomy to avoid the risk of possible bile duct injury (BDI). Pre-operative imaging study trough ultrasound and especially cMRI is crucial to recognize possible difficulties and to plan the surgery.

Histopathological changes in gall bladder mucosa in relation to the number, and size of gallstones, and analysis of the findings in the context of age distribution of the patients: A perspective

Backgrounds/Aims

To study histopathological changes in gall bladder mucosa in cholelithiasis patients, and analyse their relation to the number and size of gallstones. These findings were evaluated in the context of age distribution of the study population.

Methods

One hundred cases of cholecystectomy were part of the study, which was conducted in collaboration with the pathology department. The time period of the study was January 2020 to June 2021.

Results

Maximum cases had multiple stones (69.0%), while one third cases (31.0%) had solitary stones. While initial univariate analysis showed age (odds ratio [OR], 6.882; p = 0.043), gallstone number (OR, 9.1; p = 0.050), gallstone size (OR, 17.111; p = 0.013), and duration of symptom (OR, 34.125; p = 0.001) to be significant risk factors associated with gallbladder carcinoma, multivariate analysis found none of these variables to be significant. However, conditional multivariate analysis for the duration of symptom (p = 0.008; OR, 21.118) yielded significant p- value. With histopathological diagnoses, 5% of cases had gallbladder cancer.

Conclusions

This study shed light on the rising incidence of cholelithiasis in the young population and the high rate of gallbladder carcinoma in Punjab, India. Although gall stone characteristics (size, number) and patient age appeared to be significant risk factors when their individual relation with gallbladder carcinoma was studied, multivariate analysis, could not prove that. Conditional multivariate analysis showed the duration of symptom to be the only significant risk factor associated with gallbladder carcinoma. Further research with larger sample size is needed to study the rising incidence of gallbladder carcinoma, and the risk factors associated with it.

Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children

BACKGROUND

Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children.

STUDY DESIGN

A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05.

RESULTS

A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL.

CONCLUSIONS

Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.

Clinical Profile of Acute Pancreatitis in Children and Adolescents from a Single Center in Northern India

Introduction

There has been an increase in incidence of pancreatitis in children all over the world; studies in developed countries shown multiple etiological factors such as drugs, infections, trauma, anatomic abnormalities, and/or genetic pancreatitis in children; however, there are sparse data from the developing countries. This study was undertaken to determine the characteristics of Indian children with acute pancreatitis (AP), mainly the clinical features, etiology, complication, association, genetic factors, and outcome and recurrence.

Methods

We performed a retrospective study of all patients under the age of 18 years, who had a final diagnosis of pancreatitis admitted at our center between 2017 and 2019.

Results

During the 3-year period from 2017 to 2019, 40 patients were admitted at our center with AP. We found a definite etiology in 62.5% cases of patients, which were broadly grouped into seven etiologies: structural, genetic, drug induced, concurrent illness, cholelithiasis related, metabolic, and autoimmune. Recurrence of acute episodes was noted in 13 patients (32.5%). Of these, 11 were found to have a genetic mutation, underlying structural abnormality, or concurrent illness. In our study, we found that 23 patients (57.5%) had mild AP, while 14 patients (35%) had moderately severe pancreatitis; however, 3 patients (7.5%) had severe AP.

Discussion

We found that most cases of pancreatitis in children were of mild severity, and the etiology was quite different than adults, and most cases of acute recurrent pancreatitis have a definite etiology of either genetic mutation or structural anomaly.

The Etiology of Cholelithiasis in Children and Adolescents-A Literature Review

The incidence of gallstone disease has increased in recent years. The pathogenesis of cholelithiasis is not fully understood. The occurrence of the disease is influenced by both genetic and environmental factors. This article reviews the literature on cholelithiasis in children, with the exception of articles on hematological causes of cholelithiasis and cholelithiasis surgery. The aim of this review is to present the latest research on the pathogenesis of gallstone disease in children. The paper discusses the influence of all factors known so far, such as genetic predisposition, age, infections, medications used, parenteral nutrition, and comorbidities, on the development of gallstone disease. The course of cholelithiasis in the pediatric population is complex, ranging from asymptomatic to life-threatening. Understanding the course of the disease and predisposing factors can result in a faster diagnosis of the disease and administration of appropriate treatment.

Laparoscopic cholecystectomy in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the procedure of choice for the removal of gallbladder within the paediatric population. The aim of this study was to perform a systematic review and meta-analysis of the literature spanning the last 20 years to understand the indications for and safety of LCs in children.

METHODS

A comprehensive search of the published English language literature from January 2000 to June 2020 was done on PubMed, MEDLINE, and Google Scholar.

RESULTS

In total, 76,524 LC cases were identified from 114 studies. 78.9% of the patients were female and average age was 12 years old. Associated haematological disorders were identified in 16% of cases. The commonest indication for LC was cholelithiasis (68.4% in 66 studies), followed by cholecystitis (59.2% in 53 studies). Median operating time was 77 min. Median hospital stay was 2 days. The overall postoperative complication rate was 3.4% Major complications included bile duct injury (0.4%) and intra- or post-operative bleeding (0.9%). The conversion rate to open procedure was 2%. When comparing post-operative outcomes between emergency and elective admissions, three papers lent themselves to meta-analysis demonstrating no significant difference (p = 0.42). There was no statistically significant difference in postoperative complication rate between "hot" and "cold" laparoscopic cholecystectomies (p = 0.6).

CONCLUSION

This systematic review and meta-analysis is the largest collection of subjects on laparoscopic cholecystectomies in children. Laparoscopic cholecystectomy is a safe operation in children, with complication rates similar or comparable to the adult literature. Cholelithiasis, cholecystitis and biliary dyskinesia were the commonest indications for LC.

Childhood Obesity: Position Statement of Polish Society of Pediatrics, Polish Society for Pediatric Obesity, Polish Society of Pediatric Endocrinology and Diabetes, the College of Family Physicians in Poland and Polish Association for Study on Obesity

Childhood obesity is one of the most important problems of public health. Searching was conducted by using PubMed/MEDLINE, Cochrane Library, Science Direct, MEDLINE, and EBSCO databases, from January 2022 to June 2022, for English language meta-analyses, systematic reviews, randomized clinical trials, and observational studies from all over the world. Five main topics were defined in a consensus join statement of the Polish Society of Pediatrics, Polish Society for Pediatric Obesity, Polish Society of Pediatric Endocrinology and Diabetes and Polish Association for the Study on Obesity: (1) definition, causes, consequences of obesity; (2) treatment of obesity; (3) obesity prevention; (4) the role of primary care in the prevention of obesity; (5) Recommendations for general practitioners, parents, teachers, and regional authorities. The statement outlines the role of diet, physical activity in the prevention and treatment of overweight and obesity, and gives appropriate recommendations for interventions by schools, parents, and primary health care. A multisite approach to weight control in children is recommended, taking into account the age, the severity of obesity, and the presence of obesity-related diseases. Combined interventions consisting of dietary modification, physical activity, behavioral therapy, and education are effective in improving metabolic and anthropometric indices. More actions are needed to strengthen the role of primary care in the effective prevention and treatment of obesity because a comprehensive, multi-component intervention appears to yield the best results.

Trends in Gallbladder Disease in Young Adults: A Growing Concern

Millennials (age: 25-32 years) and Generation-Z individuals (age: 10-25 years) exhibit a shift in the occurrence of gallbladder diseases, which may be related to changes in lifestyle and genetics. In light of these findings, we performed a retrospective observational study on patients who underwent gallbladder surgeries to determine the trend in gallbladder diseases in young adults. Both categorical and continuous data on 90 patients were collected between January 2020 and June 2021 and analysed retrospectively, with differences considered significant at a p-value of 0.05. The diagnosis of gallstones in young adults is presently complicated, as the signs and symptoms of biliary tract sickness differ significantly between those under and over 30 years of age. We observed that gallbladder diseases and their complications were highly common in individuals between the ages of 21 and 25 years. We discovered that gallstones were more common in teenagers than previously thought. Delays in intervention resulted in future complications which could have been avoided.

Pediatric biliary calculus disease: clinical spectrum, predisposing factors, and management outcome revisited

Background

Biliary calculus disease (BCD) is one of the most prevalent diseases and poses a significant burden to the health care system in adults. The prevalence of BCD in children and adolescents is about 0.1% and 0.6%, respectively. Although many factors have been attributed to BCD in children, exact etiopathogenesis is not clear. BCD has been extensively studied in adults, but not much literature is available in children. The current review was undertaken to study BCD in children focusing on the objectives like predisposing factors, various modes of presentation, and management outcome of BCD in children in the northern part of India.

Results

Out of 42 children, two children had a history of ceftriaxone therapy. Two underwent ileal resection. The mean reticulocyte count was 1.79%. None had G6PD deficiency or abnormal osmotic fragility test. Clinical presentation was right upper quadrant pain (n = 42, 100%), calculous cholecystitis (n = 8, 19.0%), and jaundice (n = 3, 7.14%). The majority (n = 26, 61.92%) were overweight. Only 16.6% (n = 7) children had normal body mass index (BMI), and 9.3% (n = 4) were obese. The mean BMI was 26.3 kg/m2. 85.5% of children frequently consume junk foods. The majority of calculi were GB calculi accounting for 92.8% (n = 39) whereas 7.1% (n = 3) children had CBD calculi. Thirty-five were managed by laparoscopic cholecystectomy, three were managed by non-operative management, and one was managed by open cholecystectomy; among the three cases of CBD calculi, two were managed by endoscopic retrograde cholangiopancreatography (ERCP), stenting, and CBD exploration and one was managed by ERCP sphincterotomy.

Conclusion

Diet and overweight both appear to be important risk factors for pediatric BCD. Drug-induced calculi can be safely observed.

Management of complicated biliary disease in the pediatric population

BACKGROUND

Cholesterol stones and biliary dyskinesia have replaced hemolytic disease as the primary indication for pediatric cholecystectomy. This study looks at the cohort of pediatric patients with complicated biliary disease, defined as choledocholithiasis and/or gallstone pancreatitis, to determine the incidence and best treatment options.

METHODS

A retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children's hospital was performed. Patient factors, indications for cholecystectomy, and final treatment were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High-risk patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase.

RESULTS

A total of 695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. Of the 695 cholecystectomies, 457 were performed for stone disease (66%) (64 hemolytic) and 236 (34.0%) were performed for biliary dyskinesia. Hundred and three (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated disease). In high-risk patients, 28/47 (59.6%) underwent endoscopic retrograde cholangiopancreatography/sphincterotomy. In low-risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required endoscopic retrograde cholangiopancreatography/sphincterotomy (P < .05). The indication for endoscopic retrograde cholangiopancreatography after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications.

CONCLUSION

The incidence of pediatric complicated biliary disease due to cholesterol stones is equal to that of adults. These data suggest that a patient with imaging evidence of choledocholithiasis or common bile duct enlargement may require endoscopic retrograde cholangiopancreatography, dependent on clinical course, and this should be strongly considered before cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative endoscopic retrograde cholangiopancreatography if needed.

Nationwide Evolution of Pediatric Endoscopic Retrograde Cholangiopancreatography Indications, Utilization, and Readmissions over Time

OBJECTIVES

To analyze outcome and utilization trends over time of pediatric endoscopic retrograde cholangiopancreatography (ERCP) in an all-capture US population-level study.

STUDY DESIGN

Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric (age <20 years) hospitalizations during which ERCP was performed and assessed ERCP-associated readmissions. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify hospitalization diagnoses, comorbidities, and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P < .05) of 30-day readmission.

RESULTS

A total of 11 060 hospitalized pediatric patients underwent ERCP between 2005 and 2014. Most were female (n = 8859; 81%), aged 14-20 years (n = 9342; 84%), and white (n = 4230; 45%). Most (85%) of ERCPs were therapeutic, and leading indications were biliary (n = 5350; 48%) and pancreatitis (n = 3218; 29%). Thirteen pecent of patients were readmitted post-ERCP. Odds for 30-day readmission were highest for patients with a history of liver transplantation, age 0-4 years, male sex, and obesity (P < .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than those in rural hospitals for prolonged length of stay associated with ERCP.

CONCLUSIONS

These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights into trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics, and patient comorbidities associated with pediatric post-ERCP outcomes, including readmission and length of stay.

Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis

BACKGROUND

Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis.

METHODS

After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression.

RESULTS

Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007).

CONCLUSIONS

Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

Relative Accuracy of Bioelectrical Impedance Analysis for Assessing Body Composition in Children With Severe Obesity

OBJECTIVES

The accuracy of different bioelectrical impedance analysis (BIA) devices for assessing body composition in children with obesity is unclear. We determined the relative accuracy of 2 BIA devices compared to dual x-ray absorptiometry (DXA) in obese and severely obese children.

METHODS

We measured body composition in a cross-sectional study of 78 obese children by a handheld single frequency tetrapolar BIA device (Omron), a stationary multifrequency octopolar BIA device (InBody 370) and DXA. Intermethod agreement was assessed by intraclass correlations, paired t tests, and Bland-Altman analyses.

RESULTS

Participants (37% female, age 14.8 ± 2.7 years) had mean (±standard deviation) body mass index of 36.7 ± 7.5 kg/m, body fat percentage of 46.4% ± 5.2%, and appendicular lean mass of 22.5 ± 6.0 kg by DXA. Intraclass correlations with DXA for body fat percentage were 0.39 and 0.87 for single frequency tetrapolar and multifrequency octopolar BIA devices, respectively. The single frequency tetrapolar BIA underestimated body fat percentage by 5.5% ± 2.9% (P < 0.0001). Differences between the multifrequency octopolar BIA and DXA for body fat percentage (-1.1% ± 2.8%) and appendicular lean mass (-0.3 ± 1.4 kg) were small, and 95% limits of agreement were approximately ±5%.

CONCLUSIONS

BIA machines vary in relative accuracy in measuring body composition in children who are obese and severely obese. The multifrequency octopolar BIA device accurately estimated body fat percentage and appendicular lean mass relative to DXA and has the advantage of point of care performance.

Laparoscopic Cholecystectomy for Symptomatic Cholecystic Disease in Children: Defining Surgical Timing

Background: Laparoscopic cholecystectomy (LC) is the standard of care for gallbladder (GB) pathologies. We evaluated clinical, ultrasonographic (US) data as well as histopathological findings in children affected with symptomatic cholecystic disease (SCD) who underwent LC, with the aim of defining surgical timing. Methods: We reviewed our cases who underwent elective LC (ELC) or urgent LC (ULC). Clinical, US, surgical and histological features were used to create different risk scores. Results: We considered 26 children (17 ELC/9 ULC). US signs were not different in the two groups (p > 0.05). Operating times were longer in ELC than in ULC (p = 0.01). Histopathological evaluation revealed fibrosis and atrophy in both ELC and ULC. The clinical risk score was higher in ELC compared to ULC (p < 0.001). An increased operative risk score was noted in patients with systemic inflammatory signs (OR1.98), lithotherapy (OR1.4.3) and wall thickening ≥3 mm (OR2.6). An increased histopathological risk score was detected in children with symptom duration >7 days (OR3.61), concomitant hematological disease (OR1.23) and lithotherapy (OR3.61). Conclusion: Criteria adopted in adults cannot be adopted to detect the severity of GB damage in children. A dedicated clinical and US score is mandatory to define the most appropriate surgical timing.

Pancreatitis in pre-adolescent children: a 10 year experience in the pediatric emergency department

Background

The diagnosis of pediatric pancreatitis has been increasing over the last 15 years but the etiology of this is uncertain. The population of pre-adolescent patients with pancreatitis in the emergency department has not been specifically described. Our objective was to determine the characteristics of these patients to illuminate this population and disease in order to better identify them and avoid a delay in diagnosis and treatment.

Methods

This was a retrospective descriptive study of consecutive pediatric patients under the age of 13 years between 2006 and 2016 who presented to our pediatric emergency department with a diagnosis of atraumatic pancreatitis. Patient characteristics, lab and imaging results, identified etiology of pancreatitis, and recurrence rates were recorded and evaluated.

Results

There were 139 visits, of which 85 were for a first episode of acute pancreatitis, and 54 were patients with an episode of recurrent pancreatitis. The median age for all visits was 8 years (IQ range 5–11). Of the acute cases, 26% had uncertain or undetermined etiologies of which half were thought to likely be viral related; 20% had systemic inflammatory or autoimmune diseases; 19% were associated with medications, with the most common being valproic acid; 16% were cholelithiasis-related; and 15% were found to have a genetic, congenital or structural etiology. No patients had elevated triglycerides. Those with cholelithiasis and genetic or structural defects were found to have a higher recurrence rate than those with other etiologies. There were only four patients diagnosed with chronic pancreatitis.

Conclusions

The etiology of pancreatitis in pre-adolescent children has a different distribution than in adolescents and adults, with gallstone disease less frequent and concurrent contributing illness more common. Patients on pancreatitis-causing medications or with known genetic risk or structural pancreatic problems should be tested for pancreatitis if presenting with concerning symptoms. Hypertriglyceridemia and chronic pancreatitis with evidence of pancreatic exocrine insufficiency is uncommon in this population.

More Is Less: The Advantages of Performing Concurrent Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography for Pediatric Choledocholithiasis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are standard of care for pediatric choledocholithiasis. Patients typically undergo separate procedures during hospitalization. Collaboration between surgical and gastroenterology services led to performance of both procedures concurrently during one anesthetic. We hypothesized that concurrent procedures would reduce costs without increasing complications as compared with separate procedures. Materials and Methods: We evaluated patients admitted to our institution from 2013 to 2018 with choledocholithiasis who underwent both ERCP and LC during the same admission. Fourteen patients underwent both procedures during concurrent anesthetic. Forty-two patients who underwent LC and ERCP under separate anesthetics were randomly selected to perform a 3:1 matched case-control study. Demographic and clinical data were collected, including imaging and laboratory findings, outcomes, and costs. Comparative analysis was completed with Fisher's exact and Mann-Whitney U tests. Results: On presentation, there was no difference in common bile duct size, total bilirubin, or white blood cell count between the concurrent and separate procedure cohorts. Significantly, there was no difference in total length of anesthesia (117.9 ± 40 minutes versus 119.6 ± 52 minutes, P = .747). There were also no differences in complications, emergency department visits, or readmissions. Patients who underwent concurrent procedures had significantly lower total cost of stay ($45,597 ± 11,513 versus $61,008 ± 17,960, P = .006). Conclusions: In pediatric patients with choledocholithiasis, performing LC and ERCP may be performed concurrently during one anesthetic, which decreases costs without increasing in anesthesia time or complications.

Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy

Importance

The prevalence of pediatric cholelithiasis is increasing with the epidemic of childhood obesity. With this rise, the outcomes and costs of pediatric laparoscopic cholecystectomy become an important public health and economic concern.

Objective

To assess patient and health system factors associated with the outcomes and costs after laparoscopic cholecystectomy among Canadian children.

Design, Setting, and Participants

This was a retrospective, population-based study of children 17 years and younger undergoing laparoscopic cholecystectomy from April 1, 2008, until March 31, 2015. The data source was the Canadian Institute for Health Information. The Canadian Institute for Health Information Discharge Abstract Database includes data from all Canadian hospitals. The analysis was limited to inpatient cholecystectomies. All Canadian children undergoing laparoscopic cholecystectomy were included.

Exposure

The exposure in this study was laparoscopic cholecystectomy.

Main Outcomes and Measures

The primary outcome was all-cause morbidity, a composite outcome of any complication that prolonged length of stay by 24 hours or required a second, unplanned procedure. The cost of the index admission was also calculated as a secondary outcome. These outcomes of interest were determined before data analysis. Odds ratios and 95% CIs were estimated using multilevel logistic regression models.

Results

During the study period, 3519 laparoscopic cholecystectomies were performed; of these, 79.1% (n = 2785) were in girls, and 98.0% (n = 3450) were for gallstone disease. The overall morbidity rate was 3.9% (n = 137). After adjustment, patients with comorbidities were more susceptible to morbidity (odds ratio, 2.68; 95% CI, 1.78-3.86; P < .001). Operations for gallstones were less morbid. High-volume general surgeons had lower morbidity rates compared with low-volume pediatric surgeons (odds ratio, 0.32; 95% CI, 0.12-0.69; P = .005) independent of pediatric volumes. The mean (SD) unadjusted cost of a laparoscopic cholecystectomy was $4115 ($7273). Operative indication, complications, comorbidities, emergency admission, and surgeon volume were associated with cost.

Conclusions and Relevance

The high-volume nature of adult general surgery translated to lower morbidity and cost after pediatric laparoscopic cholecystectomy, suggesting that adult volume is associated with pediatric outcomes. As the rate of pediatric gallstone disease increases, surgeon volume, rather than specialty training, should be considered when pursuing operative management.

Pediatric Laparoscopic Common Bile Duct Exploration: An Opportunity to Decrease ERCP Complications

BACKGROUND

Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two therapeutic techniques for choledocholithiasis. The preferred technique is unclear.

MATERIALS AND METHODS

We identified subjects who underwent laparoscopic cholecystectomy (LC) and IOC/CBDE or ERCP from July 1, 2006, to December 31, 2016. We retrospectively reviewed 81 patients (≤ 18 y) who received these interventions for suspected choledocholithiasis. Main outcomes analyzed were success of intervention and complications.

RESULTS

Of the 81 patients, 21 ERCPs and three endoscopic ultrasounds (EUSs) were performed before LC. Eighteen of 21 (85.7%) patients had stones or sludge cleared by ERCP, whereas 3 (14.3%) had normal common bile ducts without evidence of stones. Five of 24 (20.8%) had significant post-ERCP complications. Seven of 24 (29.2%) had more than one admission. Sixty of 81 patients underwent LC with IOC ± CBDE. Twenty one of 60 (36.2%) were found to have abnormal IOC. Eight of 15 (53.3%) attempted laparoscopic CBDE were successful. Eleven of 21 (52.4%) patients with abnormal IOC had post-LC ERCP (10) and EUS (1). Patients admitted to the Pediatric Surgery service were more likely to undergo LC first than ERCP/EUS (OR 3.46, 95% CI 1.26 to 9.45, P = 0.016). Patients undergoing LC first had a shorter length of stay (mean LOS 5.13 d versus 4.07, median 5.0 versus 3.0 d, P-value < 0.05).

CONCLUSIONS

Successful and safe laparoscopic treatment of choledocholithiasis is possible in the pediatric patient. A laparoscopic-first approach to suspected choledocholithiasis may reduce the number of procedures needed in this patient population.

In-hospital Pediatric Endoscopic Retrograde Cholangiopancreatography Is Associated With Shorter Hospitalization for Children With Choledocholithiasis

OBJECTIVES

Children with choledocholithiasis are frequently managed at tertiary children's hospitals that do not have available endoscopic retrograde cholangiopancreatography (ERCP) proceduralists. We hypothesized that patients treated at hospitals without ERCP proceduralists would have a longer hospital length of stay (LOS) than those with ERCP proceduralists.

METHODS

Charts were reviewed for patients who underwent cholecystectomy and ERCP at 3 tertiary children's hospitals over 10 years. Trauma and complicated pancreatitis patients were excluded. Comparisons between patients requiring and not requiring transfer for ERCP were made using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables.

RESULTS

One hundred and sixty-four children underwent ERCP for suspected choledocholithiasis: 79 (48%) in the transfer group and 85 (52%) in the no transfer group.Median LOS was longer for patients requiring transfer (7 vs 5 days, P < 0.0001). One-third (34%) of the transfer patients had magnetic resonance cholangiopancreatography compared to only 7% that did not require transfer (P < 0.0001). Among the 123 patients who underwent ERCP before cholecystectomy, 53% required (66/123) transfer and 47% (57/123) did not. Transfer group patients had longer median hospital LOS (P < 0.0001), more days between admission and ERCP (P < 0.0001), and more days between ERCP and surgery (P = 0.0004).

CONCLUSIONS

Overall median LOS was significantly shorter for patients who underwent ERCP at the admitting facility. Patients who underwent ERCP before cholecystectomy at hospitals without available ERCP proceduralists incurred longer LOS. There is a need for more pediatric proceduralists appropriately trained to perform ERCP in children.

Diagnosis, treatment and prevention of pediatric obesity: consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics

The Italian Consensus Position Statement on Diagnosis, Treatment and Prevention of Obesity in Children and Adolescents integrates and updates the previous guidelines to deliver an evidence based approach to the disease. The following areas were reviewed: (1) obesity definition and causes of secondary obesity; (2) physical and psychosocial comorbidities; (3) treatment and care settings; (4) prevention.The main novelties deriving from the Italian experience lie in the definition, screening of the cardiometabolic and hepatic risk factors and the endorsement of a staged approach to treatment. The evidence based efficacy of behavioral intervention versus pharmacological or surgical treatments is reported. Lastly, the prevention by promoting healthful diet, physical activity, sleep pattern, and environment is strongly recommended since the intrauterine phase.

Cholelithiasis and choledocholithiasis in children; risk factors for development

PURPOSE

To compare anthropometric data (body mass index [BMI]) in patients without lithiasis to patients with symptomatic simple cholelithiasis or choledocholithiasis.

METHODS

We retrospectively reviewed data from 147 patients undergoing laparoscopic cholecystectomy between 2001-2015. Complete growth data from 98 patients was compared with anthropometric data from the population of the Czech Republic and a control group (BMI of 100 consecutive patients without biliary stones in abdominal ultrasound who were admitted to a surgical department for suspected appendicitis).

RESULTS

The BMI of 75 children with simple cholelithiasis and 23 with choledocholithiasis was compared to the standard Czech pediatric population and to the control group. The median age (simple cholelithiasis and choledocholithiasis) was 16 years, and 35 patients (24%) had a family history of gallstones. Types of lithiasis included multiple (n = 120), solitary (n = 11), and sludge (n = 10). Five cases had polyps and one had gallbladder dysplasia. Patients with simple cholelithiasis had significantly higher BMI compared to the control group without cholelithiasis (p<0.0001) and the standard Czech population (p = 0.03). Patients with choledocholithiasis had a mean BMI significantly higher than that of the general population (p = 0.001) and the control group (p = 0.0001). Patients with choledocholithiasis had significantly higher BMI than those with simple cholelithiasis (p = 0.03).

CONCLUSION

Patients with cholelithiasis had significantly higher BMI than the general population, and patients with choledocholithiasis had significantly higher BMI than patients with simple lithiasis. Elevated BMI is a risk factor for developing choledocholithiasis. ERCP and early laparoscopic cholecystectomy in patients with choledocholithiasis offer equivalent outcomes in patients with simple cholelithiasis.

Comparative effectiveness of bariatric procedures among adolescents: the PCORnet bariatric study

Background

Bariatric surgery has been used for treatment of severe obesity in adolescents but most studies have been small and limited in follow-up.

Objectives

We hypothesized that electronic health record data could be used to compare effectiveness of bariatric procedures in adolescents.

Setting

Data were obtained from clinical research networks using a common data model to extract data from each site.

Methods

Adolescents who underwent a primary bariatric procedure from 2005 through 2015 were identified. The percent change in body mass index (BMI) at 1, 3, and 5 years was estimated using random effects linear regression for patients undergoing all operations. Propensity score adjusted estimates and 95% confidence intervals were estimated for procedures with >25 patients at each time period.

Results

This cohort of 544 adolescents was predominantly female (79%) and White (66%), with mean (±standard deviation) age of 17.3 (±1.6) years and mean BMI of 49.8 (± 7.8) kg/m². Procedures included Roux-en-Y gastric bypass (RYGB; n = 177), sleeve gastrectomy (SG; n = 306), and laparoscopic adjustable gastric banding (n = 61). For those undergoing RYGB, SG, and laparoscopic adjustable gastric banding, mean (95% confidence interval) BMI changes of −31% (−30% to −33%), −28% (−27% to −29%), and −10% (−8% to −12%), were estimated at 1 year. For RYGB and SG, BMI changes of −29% (−26% to −33%) and −25% (−22% to −28%) were estimated at 3 years.

Conclusions

Adolescents undergoing SG and RYGB experienced greater declines in BMI at 1- and 3-year follow-up time points, while laparoscopic adjustable gastric banding was significantly less effective for BMI reduction. (Surg Obes Relat Dis 2018;000:1–13.)

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.

Prevalence of Cholelithiasis Among Igbo Adult Subjects in Nnewi, Southeast Nigeria

Aim: To determine the prevalence of cholelithiasis in a Nigerian population. Subjects and Methods: A cross-sectional study of Igbo adult subjects in Nnewi, Nigeria, was conducted from June 2011 to April 2014. A sample of 3501 adult subjects’ gallbladders and associated biliary systems was evaluated by sonography, and the presence or absence of cholelithiasis was documented. The age and anthropometric variables of the subjects were recorded. Results: The subjects (18-92 years) comprised 1731 men (49.4%) and 1770 women (50.6%). Only 4.4% (n = 154) had cholelithiasis. It is more common in women than men, at a ratio of 2.8:1. It is also more common in subjects with a high body mass index. Conclusion: The prevalence of cholelithiasis among the Igbo people in Nnewi is 4.40%, and it is about three times more common in women than men.

Symptomatic Gallstones in the Young: Changing Trends of the Gallstone Disease-Related Hospitalization in the State of New York: 1996 - 2010

Background

The aim of the study was to evaluate if the gallstone-related hospitalizations in the young (< 20 years of age) have increased over time in both the Bronx County and New York State as a whole.

Methods

We retrospectively reviewed 15 years (1996 - 2010) of Statewide Planning and Research Cooperative System (SPARCS) data of New York State Department of Health. Patients with ICD-9 code diagnosis of 574 (cholelithiasis) among the first three discharge diagnoses were reviewed.

Results

Total number of all cause admissions to hospitals had increased from 2.44 million to 2.77 million (1996 - 2010). However, gallstone-related hospitalizations had decreased from 1.7% to 1.2%. It was noted that there was a 30% increment in the proportion of those below 20 years of age with gallstone disease requiring hospitalization over the same period. This young patient population contributed only 2.04% to all gallstone-related hospitalizations in 1996, whereas it had increased to 2.96% in 2010. This trend was more pronounced in women, Hispanics and in those who were residing in the Bronx County as compared to all other New York counties combined.

Conclusion

The gallstone-related hospitalizations in the young (< 20 years of age) have increased over time in both the Bronx County and New York State as a whole. This could be due to increasing prevalence of risk factors such as obesity, physical inactivity, diabetes and early pregnancy.

Obesity Increases Operative Time in Children Undergoing Laparoscopic Cholecystectomy

INTRODUCTION

Few studies have assessed the impact of obesity on laparoscopic cholecystectomy (LC) in pediatric patients.

MATERIALS AND METHODS

Children who underwent LC were identified from the 2012 to 2013 American College of Surgeons' National Surgical Quality Improvement Program Pediatrics data. Patient characteristics, operative details, and outcomes were compared. Multivariable logistic regression was utilized to identify predictors of increased operative time (OT) and duration of anesthesia (DOAn).

RESULTS

In total, 1757 patients were identified. Due to low rates of obesity in children <9 years old, analyses were limited to those 9-17 (n = 1611, 43% obese). Among obese children, 80.6% were girls. A higher proportion of obese patients had diabetes (3.0% versus 1.0%, P < .01) and contaminated or dirty/infected wounds (15.1% versus 9.4%, P < .01). Complication rates were low. The most frequent indications for surgery were cholelithiasis/biliary colic (34.3%), chronic cholecystitis (26.9%), and biliary dyskinesia (18.2%). On multivariable analysis, obesity was an independent predictor of OT >90 (odds ratio [OR] 2.02; 95% confidence interval [95% CI] 1.55-2.63), and DOAn >140 minutes (OR 1.86; 95% CI 1.42-2.43).

CONCLUSIONS

Obesity is an independent risk factor for increased OT in children undergoing LC. Pediatric surgeons and anesthesiologists should be prepared for the technical and physiological challenges that obesity may pose in this patient population.

The increasing incidence of gallbladder disease in children: A 20year perspective

OBJECTIVE

The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario.

STUDY DESIGN

A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test.

RESULTS

There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%).

CONCLUSIONS

There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

Using Electronic Health Records for Population Health Research: A Review of Methods and Applications

The use and functionality of electronic health records (EHRs) have increased rapidly in the past decade. Although the primary purpose of EHRs is clinical, researchers have used them to conduct epidemiologic investigations, ranging from cross-sectional studies within a given hospital to longitudinal studies on geographically distributed patients. Herein, we describe EHRs, examine their use in population health research, and compare them with traditional epidemiologic methods. We describe diverse research applications that benefit from the large sample sizes and generalizable patient populations afforded by EHRs. These have included reevaluation of prior findings, a range of diseases and subgroups, environmental and social epidemiology, stigmatized conditions, predictive modeling, and evaluation of natural experiments. Although studies using primary data collection methods may have more reliable data and better population retention, EHR-based studies are less expensive and require less time to complete. Future EHR epidemiology with enhanced collection of social/behavior measures, linkage with vital records, and integration of emerging technologies such as personal sensing could improve clinical care and population health.

The development of youth-onset severe obesity in urban US girls

•

Youth-onset severe obesity warrants particular concern in urban female populations.

•

Among 2226 girls, prevalence was 8.3% at age 7–10, 10.8% at age 12–15 and fairly stable over teen years.

•

Severe obesity prevalence increased more rapidly with age for girls born in 1995 versus 1992.

•

Severely obese girls' BMI grew 2.6 times as fast as normal-BMI peers in the transition to adolescence.

•

Late childhood and early adolescence is a key developmental window for prevention and treatment.

Objective

To understand the incidence and persistence of severe obesity (≥1.2 × 95th BMI percentile-for-age) in girls across the transition to adolescence, and map developmental trajectories of adolescent severe obesity in a high-risk sample.

Methods

We examined ten years of prospectively collected data from a population sample of urban girls (n = 2226; 53% African American, aged 7–10 in 2003–2004). We determined severe obesity prevalence and incidence by age. Logistic regression evaluated for secular trend in the association between age and severe obesity prevalence. Unconditional latent growth curve models (LGCMs) compared BMI development through the adolescence transition between girls with severe obesity versus healthy BMI.

Results

Severe obesity prevalence was 8.3% at age 7–10 and 10.1% at age 16–19 (white: 5.9%; African American: 13.2%; p < 0.001). Age-specific prevalence increased more rapidly among the latest-born, versus earliest-born, girls (p = 0.034). Incidence was 1.3% to 2.4% annually. When we compared 12–15 year-old girls with severe obesity versus healthy BMI, average body weight was already distinct 5 years earlier (16.5 kg versus 25.7 kg; p < 0.001) and the BMI difference between groups increased annually. LGCMs between ages 7–10 and 11–14 indicated an increase of 3.32 kg/m² in the healthy-BMI group and 8.50 kg/m² in the severe obesity group, a 2.6-fold difference.

Conclusions

Youth-onset severe obesity warrants particular concern in urban girls due to high prevalence and an increasing secular prevalence trend. Late childhood and early adolescence may represent a key developmental window for prevention and treatment, but is too late to prevent youth-onset severe obesity entirely.

Promoting an obesity education program among minority patients in a single urban pediatric Emergency Department (ED)

Background

The purpose of this study was to assess the feasibility of the Emergency Department (ED) as a place for obesity education and to evaluate its impact on patient’s lifestyle modification.

Methods

In this study, children between 8 and 18 years of age, who presented to the ED for non-urgent reasons in a single urban hospital, were enrolled. Parents’ perception of their child’s diet and exercise were assessed prior to the intervention. Both parents and children attended a brief audio-visual presentation that provided educational information on age-appropriate diet and exercise. Following the intervention, the participants were asked about their impressions regarding the ED as a place to receive obesity education and whether they plan to make any changes in diet and exercise.

Results

One hundred children and their parents participated in this study. Of these, 76 were Latino and 21 were African-Americans. The mean age was 14 years, and the mean body mass index (BMI) was 25.6. Following the intervention, 21 (100 %) of the African-American parents and 73 (98.6 %) of the Latino parents felt that the ED should provide obesity education. Eighteen (85.7 %) of the African-American parents and 72 (97.3 %) of the Latino parents planned to make changes in their child’s diet and exercise. Among the children, 21 (100 %) of African-American participants and 76 (100 %) of Latino participants reported that they found the audio-visual useful. Seventeen (81.0 %) of the African-American children and 73 (96.1 %) of Latino children stated learning new information from the intervention program.

Conclusions

This study suggests the ED may have a role in primary health promotion and obesity prevention. An ED-based intervention may be used to provide education about obesity prevention and has the potential to impact life style modifications, including diet and exercise.

Early cholecystectomy in children with gallstone pancreatitis reduces readmissions

BACKGROUND

Multiple guidelines exist in adult practice regarding the timing of cholecystectomy for gallstone pancreatitis. Current evidence to support their application to pediatric practice is minimal. This study sought to determine the effect of timing of cholecystectomy for gallstone pancreatitis in children on the risk of readmission.

METHOD

All patients younger than 19years of age presenting to an acute NHS trust in England with a diagnosis of gallstone pancreatitis between 1 January 1999 and 31st December 2009 were included. Patient level data were extracted from the English Hospital Episode Statistic Database. ICD10, OPCS4.6 and hospital administrative data were used to determine: diagnosis, age, associated comorbidities and subsequent procedures performed.

RESULTS

670 cases of gallstone related pancreatitis were recorded in younger than 19 years old between 1999 and 2009 resulting in 3 deaths during this period. The majority (534/670) underwent a cholecystectomy which was performed less than two weeks from primary admission in 33% (174/534) of cases. Cholecystectomy within two weeks provides an actual risk reduction (ARR) of readmission of 57.5% (95% CI 50.1 to 64.4%, p<0.0001, NNT 2). No significant difference was identified in operative complications or mortality following early cholecystectomy in this group (p>0.05).

CONCLUSIONS

Readmissions can be significantly reduced in this population by performing a cholecystectomy within two weeks with no apparent rise in surgical complications.

Pediatric obesity. An introduction

The prevalence of child and adolescent obesity in the United States increased dramatically between 1970 and 2000, and there are few indications that the rates of childhood obesity are decreasing. Obesity is associated with myriad medical, psychological, and neurocognitive abnormalities that impact children's health and quality of life. Genotypic variation is important in determining the susceptibility of individual children to undue gains in adiposity; however, the rapid increase in pediatric obesity prevalence suggests that changes to children's environments and/or to their learned behaviors may dramatically affect body weight regulation. This paper presents an overview of the epidemiology, consequences, and etiopathogenesis of pediatric obesity, serving as a general introduction to the subsequent papers in this Special Issue that address aspects of childhood obesity and cognition in detail.

A snapshot of cancer in Chile: analytical frameworks for developing a cancer policy

INTRODUCTION

The South American country Chile now boasts a life expectancy of over 80 years. As a consequence, Chile now faces the increasing social and economic burden of cancer and must implement political policy to deliver equitable cancer care. Hindering the development of a national cancer policy is the lack of comprehensive analysis of cancer infrastructure and economic impact.

OBJECTIVES

Evaluate existing cancer policy, the extent of national investigation and the socio-economic impact of cancer to deliver guidelines for the framing of an equitable national cancer policy.

METHODS

Burden, research and care-policy systems were assessed by triangulating objective system metrics--epidemiological, economic, etc.--with political and policy analysis. Analysis of the literature and governmental databases was performed. The oncology community was interviewed and surveyed.

RESULTS

Chile utilizes 1% of its gross domestic product on cancer care and treatment. We estimate that the economic impact as measured in Disability Adjusted Life Years to be US$ 3.5 billion. Persistent inequalities still occur in cancer distribution and treatment. A high quality cancer research community is expanding, however, insufficient funding is directed towards disproportionally prevalent stomach, lung and gallbladder cancers.

CONCLUSIONS

Chile has a rapidly ageing population wherein 40% smoke, 67% are overweight and 18% abuse alcohol, and thus the corresponding burden of cancer will have a negative impact on an affordable health care system. We conclude that the Chilean government must develop a national cancer strategy, which the authors outline herein and believe is essential to permit equitable cancer care for the country.

Prevalence of and risk factors for gallstones in Uighur and Han Chinese

AIM: To perform a single-centre survey of the prevalence of and possible risk factors for gallstones in Uighur and Han Chinese.

METHODS: Complete medical data for 9455 patients were collected from the medical centre of our hospital, and the overall prevalence of gallstones as well as the prevalence in different ethnic groups was studied. The risk factors for gallstones in different ethnic groups were identified in a univariate analysis, and variables with statistical significance were analysed by unconditional multiple logistic regression, to primarily explore the similarities and differences in gallstone risk factors between different ethnic groups.

RESULTS: The prevalence of gallstones was significantly higher in the Uighur population than in the Han population (22.87% vs 11.64%, P < 0.05). Further analysis of risk factors for gallstones based on the different ethnic areas revealed that age was a risk factor for gallstones in both groups; triglycerides, body-mass index (BMI) and high-density lipoprotein were risk factors for gallstones in the Han population, while total cholesterol (TC), gender and fatty liver were risk factors in the Uighur population. The Uighur patients were older than the Han patients, and had higher BMI, TC, low-density lipoprotein, female rate and fatty liver rate, while the incidence of hypertension was lower than that in the Han patients.

CONCLUSION: The prevalence of and risk factors for gallstones differ between the Uighur and Han populations.