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Timing of Cholecystectomy in Children With Biliary Pancreatitis, Early Versus Delayed Surgery: a Single Pediatric Center Review
Tom K. Lin*1, Joseph J. Palermo1, Jaimie D. Nathan2, Greg M. Tiao2, Maisam Abu-El-Haija1
1Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; 2Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
Objective: Biliary pancreatitis (BP) is a common cause of acute pancreatitis (AP) in adults and children. Current standard of care is to perform a cholecystectomy (CCE) to decrease the recurrence risk of AP. Controversy exists as to the timing of CCE, early (during index admission) versus delayed surgical intervention. Adult literature suggests a greater benefit of early CCE. However, there is limited literature as to the optimal timing of CCE in children. We sought to identify at our institution the frequency of adverse events in children with BP undergoing early versus delayed CCE.
Methods: We conducted a retrospective chart review of all children admitted with AP from January 1, 2010 to July 24, 2013. We then queried for all patients who had also undergone a CCE as documented in the individual charts. Patients who underwent a CCE for reasons other than BP were excluded from this review. Patient demographic information, BMI, the date of presentation with BP, CCE operative date, and complications or adverse events occurring from CCE were recorded. Early CCE was defined as undergoing a CCE during the index admission; late CCE was defined as a CCE performed during a subsequent admission.
Results: A total of 285 cases with AP were identified, of which 31 patients were found to have undergone a CCE. Twelve patients were excluded because the CCE was performed for an indication other than BP. The study group of 19 patients (17 female, 2 male) had a mean age of 15 years (range 8-20 years). Two patients were found to be overweight (BMI 85th to 95th percentile) and 7 patients were characterized as obese (BMI >=95th percentile). CCE was performed early in 9 patients with no pre- or post-surgical adverse events, and mean length of stay following CCE was 1.1 days. In the ten patients who had a delayed CCE, AP recurred in 1 and abdominal pain without AP consistent with biliary colic occurred in 3. The duration between the initial presentations with BP to the time of delayed CCE ranged from 8 to 90 days (mean 34 days, median 27 days). CCE was delayed 90 days in one patient with recurrent AP because of multiple co-morbid conditions. AP was considered to be severe in only 1 patient with a complication of pancreatic necrosis. In this patient, CCE was performed 81 days after initial presentation without the occurrence of any interval adverse events.
Conclusion: Gallstone related events including biliary colic and recurrent pancreatitis can occur at a high rate in children with BP who undergo a delayed CCE. Adverse events and surgical complications from early CCE are uncommon in children with non-severe BP. Early CCE during the index admission should be considered as the preferred timing for surgical intervention.
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