Safety and efficacy of laparoscopic cholecystectomy in preschool children
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Cholecystectomy is rarely performed in preschool children and limited data exist evaluating the extent of utilization and safety of laparoscopic cholecystectomy (LC) in preschool children. The aim of this study was to investigate the safety and efficacy of LC in preschool children.
Materials and methods
This study was conducted from May 2013 to June 2017 and included preschool children from 1 to 6 years of age having gallstones and biliary dyskinesia. The parameters which were studied included bile leak, ductal injury, trocar and pneumoperitoneum-related complication, operative time, duration of hospital stay and recovery.
Thirty-three patients underwent laparoscopic cholecystectomy. There were 19 males and 14 females. The age of patients ranged from 7 months to 6 years with mean age of 3.2 years. Weight of patients ranged from 8–20 kg with mean weight of 10.4 kg. Gallstones were present in 29 patients and biliary dyskinesia in four patients. Operative time ranged from 55–130 min with mean operative time of 73 min. Duration of hospital stay ranged from 24–80 h with mean duration of hospital stay of 28 h. Bile leak occurred in one patient. There was no bile duct injury in this series.
Laparoscopic cholecystectomy is safe and efficacious in preschool children with gallstones and biliary dyskinesia.
KeywordsLaparoscopic cholecystectomy Preschool Safety and efficacy
Laparoscopic cholecystectomy in children is relatively uncommon, despite being one of the most common surgical procedures in adults [1, 2]. However, over the past two decades, the number of laparoscopic cholecystectomy in children has increased [3, 4]. Studies on western population have shown increased rate of laparoscopic cholecystectomy in children, and biliary dyskinesia is the common cause [5, 6]. The distribution of disease processes requiring the cholecystectomy is different in children as compared to adults.
Laparoscopic cholecystectomy has become a safe operation performed throughout the world. The operation is more commonly performed in adults. Despite the exponentially increasing number of laparoscopic cholecystectomies in adults with good documentation of safety and efficacy, in children, there is paucity of data in the literature. Laparoscopy itself in children is technically challenging because of a discrepancy between the length of the instruments, size of the peritoneal cavity, large viscera, no fixed port placement sites, short aorto-abdominal axis, etc.
During the past 10–15 years, laparoscopic cholecystectomy has become the preferred technique for the pediatric gallbladder disease. However, safety, efficacy and complications of laparoscopic cholecystectomy in preschool children have not been clearly characterised. To the best of our knowledge, there is no single large study on laparoscopic cholecystectomy in preschool (1–6 years) children. The aim of this study was to evaluate the safety, efficacy and complications of laparoscopic cholecystectomy in preschool children with gallstone disease.
Materials and methods
This study was conducted in the Department of Paediatric and Neonatal surgery SKIMS, Srinagar, India, from May 2013 to June 2017. Preschool children from 1–6 years of age having gallstones and biliary dyskinesia were included in the study. Laparoscopic cholecystectomy was done in all children. Three 5mm and one 10mm port were used. Pneumoperitoneum pressure was maintained at 8 mm Hg. Duct and vessels were ligated with 5 mm clips. Gallbladder was dissected from the bed and removed through the 10 mm umbilical port. Postoperatively, the various parameters which were studied include bile leak, ductal injury, trocar and pneumoperitoneum-related complication, operative time, duration of hospital stay and recovery. Patients with choledochal cyst, biliary atresia and choledocholelithiasis were excluded from the study.
Clinical profile of patients
0–2 years (n = 9)
1. Symptomatic (8): refusal of feeds, vomiting, fever, irritability.
2. Asymptomatic (1): incidental detection.
2.6 years (n = 24)
1. Symptomatic (17): pain abdomen, vomiting, fat intolerance.
2. Asymptomatic (3).
3. Biliary dyskinesia (4): on HIDA scan, mean ejection fraction 23% (range 13–30%)
Laparoscopic cholecystectomy has become a gold standard for the management of gallbladder disease. In adults, there is lot of literature about the laparoscopic cholecystectomy . However, in children particularly in preschool children, there is paucity of data regarding the safety, efficacy and complications of laparoscopic cholecystectomy . Laparoscopy in children is challenging, even more difficult in preschool age group due to a number of factors such as small size of the peritoneal cavity, large viscera and less volume of cases.
Indications of cholecystectomy are different in children than adults. Recently, many studies in western population have reported increased prevalence of cholecystectomy due to gall stones in children [3, 4, 8, 9]. In our study, 33 preschool children underwent laparoscopic cholecystectomy, 29 (87.9%) patients have gall stones and 4 (12.1%) have biliary dyskinesia. In children, asymptomatic gallstones are less frequent, with reported incidence of 17–50% . Deepak et al. have reported asymptomatic gallstones in 5.6% of patients . In our patients, asymptomatic gallstones were seen in 12.1%.
In adults where natural history is well documented, only 1–4% per year develop symptoms or complications of gallstone disease, only 10% develop symptoms in the first 5 years after diagnosis, and approximately 20% by 20 years . Hence, in adults, prophylactic cholecystectomy is not recommended for asymptomatic gallstones. However, the picture is not so clear in children .
Pathogenesis of gallstones and sludge in children is still unclear . As little is known about the natural history of childhood cholelithiasis, guidelines for management are lacking . It has been observed that most of the time the gallstones remain un-detected in pediatric population until complications develop . As non-surgical approaches have proved ineffective due to severe restriction on their applicability, laparoscopic cholecystectomy is considered the gold standard treatment in children also with minimal morbidity and mortality [16, 17].
Deepak et al. suggested laparoscopic cholecystectomy for all children with cholelithiasis . A multicentre study also reports structural alterations in the majority of gallbladders removed for cholelithiasis. These authors also suggest that because of long life expectancy of children, expectant management of cholelithiasis may not be safe . Due to high incidence of serious complications of gallstones in children, conservative management of gallstones may not be safe and hence laparoscopic cholecystectomy must be done even in asymptomatic cholelithiasis . However, other authors suggested that asymptomatic children or children with nonspecific symptoms can undergo safe follow-up [12, 18]. In our study, in children with asymptomatic gallstones, which cannot be followed up safely, laparoscopic cholecystectomy was done to prevent serious complications of gallstones in future.
Biliary dyskinesia is becoming diagnosed more frequently in the children [6, 19]. The management of this condition is a subject of debate in the literature. Hossam et al. conducted study on efficacy of cholecystectomy in children diagnosed with biliary dyskinesia . The authors noted that children with biliary dyskinesia benefit from cholecystectomy. Vegunta et al. and Scott Nelson et al. also noted that children with biliary dyskinesia do well with cholecystectomy . Children with biliary dyskinesia have an increase in number of inflammatory cells in the gallbladder mucosa comparable to those patients with stone disease. This provides biologic credibility for gallbladder removal in these patients . Laparoscopic cholecystectomy is safe and effective in children with biliary dyskinesia. There is significant improvement in symptoms after the cholecystectomy in children with biliary dyskinesia and support to cholecystectomy in children to treat biliary dyskinesia [5, 22]. In our study, diagnosis of biliary dyskinesia was made in children with persistent abdominal pain, normal ultrasonography (US), gallbladder is less contractile and gallbladder ejection fraction is less than 35% at 30 min on HIDA scan. Four patients were with biliary dyskinesia, in which mean ejection fraction was 23% (range 13–30%). Laparoscopic cholecystectomy was done in all patients and postoperatively symptoms improved in all cases.
Bile leaks are an annoying complications after a cholecystectomy but pose less significant management issues than ductal injuries. Bile leak after laparoscopic cholecystectomy can be due to slip of cystic duct clip, from the gallbladder fossa (ducts of Luschka) or due to some ductal injury. Early and accurate diagnosis is mandatory to determine the appropriate management. Most of these postoperative leaks resolve with the sphincterotomy or stent placement [23, 24]. In our study, bile leak occurred in one patient, who was managed by sphincterotomy.
Bile duct injury is a well-documented complication of cholecystectomy with an incidence of 1 per 1000 laparoscopic cholecystectomies in adults . However, there is no good documentation of ductal injuries in children. The prevalence of BDI in children reported in two large retrospective reviews of administrative databases ranges from 0.36 to 0.44% [26, 27]. The possible causes of bile duct injuries are abnormal anatomy, bleeding, adhesions, severe inflammation, injudicious use of electric cautery, and early phase of learning curve. We did not encounter any bile duct injury in our patients.
Thus, laparoscopic cholecystectomy in preschool children is safe, and efficacious with good outcome and minimal morbidity. It has all advantages of minimally invasive technique with less pain, scar less, short duration of hospital stay and early recovery.
There is risk of colorectal cancer (CRC) in the long term after cholecystectomy. The association between cholecystectomy and CRC has been of interest due to multiple potential biological mechanisms. Bile acid, which is synthesized in the liver and stored in the gallbladder, is known to be carcinogenic for CRC. As a result of cholecystectomy, the exposure time of the intestinal mucosa to bile acid secretions increases, and cholecystectomy enhances negative feedback on bile acid synthesis in the liver, which could possibly alter the risk of CRC development . Some of these studies have reported a modestly increased risk of CRC after cholecystectomy, but others reported no such association . Children need to be followed for long term after cholecystectomy for possible risk of colorectal cancer (CRC) and we are committed to follow our children.
Laparoscopic cholecystectomy is a gold standard treatment for the gallstones and biliary dyskinesia. It is safe and efficacious in preschool children with good results and minimal morbidity. It has all advantages of minimally invasive technique. To prevent serious complications of gallstones in future, we support the laparoscopic cholecystectomy in children with asymptomatic gallstones which cannot be followed up safely. There is significant improvement in symptoms after cholecystectomy in patients with biliary dyskinesia.
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