S. B. Cairo1, G. Ventro1, E. Sandoval3, D. H. Rothstein1,2 1Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NEW YORK, USA 2University At Buffalo Jacobs School Of Medicine And Biomedical Sciences,Division Of Surgery,Buffalo, NY, USA 3Jacobs School Of Medicine And Biomedical Sciences,Buffalo, NEW YORK, USA
Introduction: Rates of cholecystectomy in pediatric patients have risen dramatically in the past decade, driven in part by an increased acceptance of biliary dyskinesia as a principle indication. Symptom improvement after cholecystectomy in this group, however, is disappointingly inconsistent. We seek to characterize post-operative resource utilization in patients with persistent symptoms after cholecystectomy for biliary dyskinesia.
Methods: Single-institution, retrospective chart review of patients less than 18 years old who underwent cholecystectomy for an ICD9 diagnostic code of biliary dyskinesia between December 1, 2010 and July 2, 2016. Patient demographics, symptoms, pre-operative workups, operative details and post-operative interventions were abstracted. Telephone follow-up was performed to identify patients with persistent symptoms, characterize the patient experience, and quantify post-operative resource utilization.
Results: Forty-nine patients underwent cholecystectomy for biliary dyskinesia. All of the procedures were performed laparoscopically without intraoperative cholangiogram. Nearly half (22, 45%) were seen post-operatively by a gastroenterologist, 32% of whom were known to a gastroenterologist prior to cholecystectomy, as well. Post-operative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, 5 ERCPs, 1 endoscopic ultrasound, 1 MRCP, and 5 colonoscopies. Only 2 patients had undergone ERCP pre-operatively in this cohort. Of the patients with additional diagnostic testing post-operatively, one was found to have mild esophagitis, 3 were diagnosed with Sphincter of Oddi dysfunction, and 1 was diagnosed with suspected inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea or vomiting at an average of 26 months after operation. Of note, all patients who underwent post-operative ERCP with sphincterotomy reported symptom relief following this procedure.
Conclusion: Relief of symptoms after cholecystectomy for biliary dyskinesia in the pediatric population is inconsistent. Post-operative studies are myriad, and have no consistent diagnostic yield and generate high costs. The volume and inconclusive nature of post-operative work up for patients with ongoing symptoms suggests that the initial diagnostic criteria and treatment algorithm may require revision.