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Journal of Pediatric Surgery 51 (2016) 264267

Contents lists available at ScienceDirect

Journal of Pediatric Surgery


journal homepage: www.elsevier.com/locate/jpedsurg

Childhood cholecystectomy in New Zealand: A multicenter national


10 year perspective
Sandra Campbell a,, Ben Richardson b, Prabal Mishra c, Marilyn Wong d, Udaya Samarakkody a,
Spencer Beasley b, Kevin Pringle c, Philip Morreau d
a
Waikids Surgical Department, Waikato District Health Board, Hamilton, New Zealand
b
Christchurch Department of Paediatric Surgery, Canterbury District Health Board, Christchurch, New Zealand
c
Wellington Childrens Surgical Department, Capital and Coast District Health Board, Wellington, New Zealand
d
Starship Childrens Hospital, Auckland District Health Board, Auckland, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: Aim: International studies show increasing incidence of cholelithiasis in childhood and an increasing caseload for
Received 24 October 2015 the pediatric surgeon. We reviewed pediatric cholecystectomy in all four centers in New Zealand, examining
Accepted 30 October 2015 changes in incidence and the demographics of the patient population.
Method: Coding data were used to retrieve case notes and extract demographic data, diagnosis, comorbidities,
Key words: length of stay, and complications for patients less than 16 years old undergoing cholecystectomy from January
Cholecystectomy
1st, 2004December 31st, 2013. Patients with congenital biliary malformations were excluded. Statistical analy-
Gallstones
Obesity
sis was performed using SPSS.
Risk factors Results: 170 children required cholecystectomy. On average, 15 procedures were performed annually (IQR 824).
New Zealand There was a slight upward trend, with a gradient of 0.34 (P = 0.63). Median age was 14 (range 215) years,
male:female 2:3. While 72% of children were Caucasian, Mori were signicantly overrepresented (20%). Numbers
of Pacic Islander increased signicantly over time (P = 0.05), in line with population increases. Of 114 patients
with complete dataset, 31% were overweight or obese. Complication rates were 8.8% overall, but 27% of complica-
tions occurred in Mori children. 40% of those suffering a complication were obese. Three complications were major,
requiring return to theater. Mean length of stay was 5 days.
Conclusions: New Zealand has not seen the rapid increase in pediatric cholecystectomy experienced elsewhere in
the OECD. However, the problem of adolescent biliary disease is prevalent. The average recipient of a cholecystec-
tomy is 14 years old, overweight, and Caucasian; though Mori have a high relative risk of both biliary disease and
complicated postoperative course. The reasons for this remain unclear and require further study.
2016 Elsevier Inc. All rights reserved.

Several countries within the Organisation for Economic Cooperation tended to be non-Caucasian, were the commonest group requiring
and Development (OECD) have observed rapidly changing demo- cholecystectomy. While their study was limited by lack of data on
graphics for gallstone disease in children. Langballe et al. [1] found 196 obesity, they speculated that this is the likeliest contributing factor.
in a review of cholecystectomies in children in Denmark, a county This hypothesis is supported by a retrospective analysis of children
with a high standard of living and low levels of obesity. Five percent undergoing cholecystectomy more than 3 years from 20052008 in
had congenital factors or comorbidities predisposing them to biliary Texas [3]. The median body mass index (BMI) centile was 89%, and 39%
disease and 82% were female, 50% were overweight with 33% being of their patients were obese. They were able to compare their current
dened as obese. By comparison, Khoo et al. [2] in England noted a dataset with a historical dataset from 19801996 and found that the
three-fold increase in the incidence of cholecystectomy more than a rates of Hispanic ethnicity and obesity had also signicantly increased in
15 year period from 0.78/100,000 to 2.7/100,000, predominantly in their cohort.
Caucasian females. Previously, children with hemolytic anemias who New Zealand has no previous data on rates of cholecystectomy in
childhood, or of the predisposing factors for childhood biliary disease.
As it has a similar size of population to Denmark, one might expect
similar numbers of cases. Its unique ethnic make-up and the growing
Corresponding author at: Paediatric Surgical Department, Waikato Hospital, Pembroke childhood obesity epidemic [68] prompted us to examine our data.
Street, Hamilton, Waikato, 3200, New Zealand. Tel.: +64 27 9732007/+64 7 8398716;
fax: +64 7 8398765.
Our primary aim was to determine whether rates of cholecystectomy
E-mail addresses: Sandra.campbell@waikatodhb.health.nz, in New Zealand were increasing as observed elsewhere in the OECD.
Sandrajanecampbell@gmail.com (S. Campbell). Additionally we wished to identify the risk factors for pediatric

http://dx.doi.org/10.1016/j.jpedsurg.2015.10.071
0022-3468/ 2016 Elsevier Inc. All rights reserved.
S. Campbell et al. / Journal of Pediatric Surgery 51 (2016) 264267 265

cholelithiasis in our population and examine the operative outcomes


including complications and lengths of stay.

2. Methods

Clinical coding data were used to obtain patient information for all
children aged between 0 and 15 years old, who had undergone a chole-
cystectomy from January 1st 2004 to December 31st 2014, in any of the
four tertiary pediatric surgical centers in New Zealand. All children in
New Zealand requiring elective or complex surgery are referred to pedi-
atric surgical centers, so we believe that we can capture national data
with some condence.
Case notes were retrieved and data were extracted on age, sex,
ethnicity, obesity (underlying diagnosis/weight/height/BMI data),
presentation, comorbidities, type of operation, length of stay and
complications. Patients with congenital biliary malformation were
excluded from the study.
These data were collated in Microsoft Excel and analyzed using SPSS.
Regression analysis was used to examine changes in numbers over
time; while Chi squared tests were used to compare categorical values.
The results were compared to population statistics from New Zealand
Census data [7,8] to illustrate the differences or trends associated with
ethnicity. The study was approved by Performance and Quality Assur- Fig. 1. Frequency of cholecystectomy by age.
ance (PQAA) authority of the respective hospitals. A P value of b 0.05
was regarded as signicant.
were overweight or obese in 70%, compared to 27% nationally. Mori
were overweight or obese in 20%, compared to 19% nationally.
3. Results The positive risk factors for requiring pediatric cholecystectomy
were increasing age, obesity, and Mori ethnicity. Fig. 2 shows relative
A total of 170 children underwent cholecystectomy during the study risks based on ethnicity and combination of obesity/overweight and
period. Complete data were available for 149 patients and information ethnicity.
relating to weight, height and operative duration was often unavailable The majority of patients (n = 117, 78.5%) presented with typical
(Table 1). Male to female ratio was 2:3. The median and mode age were features of cholelithiasis such as dyspepsia and biliary colic. Of the rest
both 14 years and this did not change over the study period. The age 20% of cholecystectomies were performed for hemolytic anemia (n =
distribution at presentation is illustrated in Fig. 1. 30). Eighteen of these had splenectomy with their cholecystectomy.
On average, 14 cases were performed each year, spread over the 4 The rate stayed steady at around 3 cases per year. Biliary dyskinesia
centers. Although there was an upward trend, at 0.34 per year, this accounted for a small percentage (5.3%), of which 45% had ongoing
was nowhere near statistically signicant (P = 0.63). symptoms on follow-up. Three (2%) of patients had cystic brosis.
In the study population 70% were European, 20% Mori and 6% Pacic Forty ve children presented with complications because of choleli-
Islander. We compared this to recent population statistics of 67% thiasis. These included pancreatitis in 18 patients (12%), obstructive
European, 14% Mori, and 7% Pacic Islander suggesting overrepresenta- jaundice in 17 (11%) and acute cholecystitis in 20 (13%).
tion by Mori. To further investigate, we calculated relative risk for differ- One hundred and forty ve patients had a laparoscopic cholecystec-
ent ethnic groups. We conrmed that Mori relative risk for requiring tomy, of which 18 procedures included splenectomy. A further 6 (4%)
cholecystectomy was high, independent of their risk of obesity. Rates of cases started laparoscopically and were converted to open. An open
Pacic Islander undergoing cholecystectomy increased over the study procedure was planned in 7 cases, of which 5 occurred in the rst
period. However, this may reect an increasing Pacic Islander popula- 5 years of the study. The main reason for planning an open procedure
tion in New Zealand over this time period [7]. was either to operate on the pancreas at the same time (n = 3), or for
In those with BMI data available, 31% of patients were overweight or a planned common bile duct exploration (n = 2).
obese. This compared to 11% of children nationally [8]. Pacic Islander A laparoscopic common bile duct exploration was undertaken in 3
cases, and these recorded the longest operating times (mean =
159 min). Thirty ve (25%) patients underwent either MRCP or ERCP
Table 1
Baseline demographic data. preoperatively. Additionally, 8 procedures included intraoperative chol-
angiography. Of 12 patients having ERCP, 4 underwent sphincterotomy
Number Percentage Census data
to facilitate expulsion of common bile duct stones prior to cholecystec-
Center tomy (Table 2).
Auckland 66 39% 33% The hospital length of stay varied according to the type of procedure
Hamilton 33 19% 9.6%
Wellington 21 12% 8.8%
performed, from 3 days for a simple cholecystectomy to 17 days for
Christchurch 50 29% 22% children requiring common bile duct exploration. For all cases, mean
Sex length of stay was 5 days, median was 2 days (IQR 112).
Male 59 38% 49% 12 patients were readmitted within 30 days (7%). There were 15
Female 95 62% 51%
complications (8.8%), of which 3 were major: 2 common bile duct inju-
Ethnicity
European 119 70% 74% ries and 1 bowel injury, all requiring return to theater. 40% of patients
Mori 34 20% 15% having a complication were obese (P b 0.05), and 27% occurred in
Pacic Islander 10 6% 7.4% Mori children (P = 0.57). The 30 day mortality rate was zero. Seven
Asian 2 1% 12% children had ongoing abdominal pain following removal of gallbladder
Other 6 3% 1.2%
(Table 3).
266 S. Campbell et al. / Journal of Pediatric Surgery 51 (2016) 264267

Fig. 2. Relative risk of cholecystectomy by factor examined.

4. Discussion causative, including those coding for apolipoproteins E and B and chole-
cystokinin receptor A [1113]. It is possible that the Mori population
The number of childhood cholecystectomies being performed in New may have a similar genetic predisposition to cholelithiasis, but this is
Zealand for symptomatic biliary disease has yet to increase signicantly yet to be investigated.
unlike in other OECD countries [24]. Cholecystectomy for gallstones not The rates of conversion from laparoscopic to open range from 0.54%
linked to hemolytic anemia or other congenital predisposing conditions with complication rates of 915% [15]. Chena et al. reported that low
accounts for about 75% of procedures performed with very few for biliary socioeconomic status and non-Caucasian ethnicity were associated
dyskinesia. Where this does happen, the rate of successful resolution of with increased complication rates and longer hospital stays.
symptoms is low. Bielefeldt et al. in Pittsburgh, USA [4], reported a 700% Overall the surgical outcomes appear acceptable despite low sur-
increase in cholecystectomy for children between 1997 and 2010. These geon volumes. Rates of complication of b 10% compare favorably with
cases were mostly covered by private insurance, in contrast to the insur- American data showing complication rates up to 15% [5]. Conversion
ance status of surgery for acute gallstone disease. Small randomized rates were higher than in the Danish study [1] at 4%. Length of stay is
trials report very little benet from cholecystectomy in these children, regarded as a good surrogate marker for clinical quality in other parts
with 5075% having ongoing symptoms postoperatively. This appears of the OECD [1]. Our lengths of stay were much longer than all compa-
comparable to our results, albeit with our small numbers in a public rable studies and we feel that this is mostly because of geographical
healthcare system. constraints. Day surgery for cholecystectomy in children is not generally
Obesity is an established risk factor for cholelithiasis, and we know accepted as an option in New Zealand and clearly this inuences deci-
that the proportion of obese children is increasing in New Zealand sion making around the timing of discharge. Rates of readmission and
(from 8% in 2006 to 11% in 2013) [8]. The relative risk of requiring a reoperation were both low, but a number of children had ongoing
childhood cholecystectomy and the risk of complications is higher in pain postoperatively.
obese children than in nonobese children. In New Zealand, obesity dis- The study is limited by the retrospective design, and consequently
proportionately affects children living in poverty, independently of age, incomplete data regarding rates of obesity and operative times. It is
sex and ethnicity [8]. Therefore, it is the most deprived children who are also possible that a small number of childhood cholecystectomies are
at risk not only from gallstones, but also from poor surgical outcomes. A being performed in regional centers by general surgeons which our
prospective design would capture better quality data regarding rates of methodology was unable to detect.
obesity among children undergoing cholecystectomy, and one might In conclusion, cholecystectomy in New Zealand for pediatric gall-
reasonably expect that the rate would increase both over time and stone disease is most common in overweight female adolescents. Our
with improved data quality. data add new information, suggesting that Mori children are at partic-
The reasons for the increased relative risk of requiring cholecystecto- ular risk, independent of other risk factors. New Zealand numbers
my, or having postoperative complications among Mori children are remain low, but are likely to increase as the obesity epidemic worsens.
unclear. This may reect the wider issue of poor health outcomes for
Mori, which is inuenced by social exclusion, racial discrimination References
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Table 2
Type of procedure and length of stay.

Procedure No Operation time (min) median (range) ERCP/MRCP Readmission Complication rate Length of stay

Open cholecystectomy 7 145 (77212) 1 1 1 10


Lap converted to open 6 145 (112230) 1 0 0 8
Lap cholecystectomy 145 95 (34145) 26 10 12 3
Intraoperative Cholangiogram 8 100 (34141) 1 0 0 5
Common Bile Duct exploration 5 159 (77230) 3 1 1 17
including splenectomy 18 141 (96212) 3 0 2 5
S. Campbell et al. / Journal of Pediatric Surgery 51 (2016) 264267 267

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