J. B. Mahida1,2, J. P. Sulkowski1,2, J. N. Cooper1, A. King1, K. J. Deans1,2, P. C. Minneci1,2, D. R. King2 1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA
Introduction: The diagnosis and management of children with biliary dyskinesia are controversial. Our objective was to identify clinical determinants of pain improvement in children undergoing cholecystectomy for biliary dyskinesia.
Methods: This retrospective institutional cohort study included patients who underwent cholecystectomy for biliary dyskinesia between 2006 and 2013. All patients had their gallbladder ejection fraction (EF) measured by either cholecystokinin stimulated HIDA scan, fatty meal ultrasound (FUS; measures the change in gallbladder volume after consumption of a high fat meal), or both. Patients without postoperative follow up were excluded. Data collected included patient demographics, medical history, preoperative imaging, details of the surgery, and postoperative outcomes. The ability of the preoperative diagnostic tests to predict pain improvement was evaluated by examining overall accuracy, sensitivity, specificity, and negative and positive predictive values (PPV). Multivariable logistic regression models were used to identify preoperative characteristics associated with pain improvement.
Results: Of the 153 included patients, 76% were female, 89% were Caucasian, and 51% were either overweight (BMI >85th to ≤ 95th percentile; 12%) or obese (BMI >95th percentile; 39%). At postoperative evaluation, improvement of pain was reported by 82% of the patients. The median (interquartile range) gallbladder EFs were not statistically different in patients with and without pain improvement for both the HIDA (pain improvement EF 18% (17-31%) vs. no pain improvement EF 22% (3-36%), p=0.66) and the FUS (EF 35% (24-50%) vs. EF 41% (33-51%), p=0.31). For both the HIDA and FUS, the sensitivity of the test to predict pain improvement increased with higher ejection fractions while the PPV remained around 80% (Table). There was no correlation between EF measurements from HIDA and FUS in patients who had both tests (N=0.29, r=28, p=0.15), neither test showed superior performance, and the results were similar in obese and non-obese patients. Preoperative characteristics that were independent predictors of pain improvement included a shorter duration of pain (odds ratio of pain relief, 95% CI, p-value) (per month: 1.02, 1.0-1.05, p=0.03), a history of vomiting (2.62, 1.02-6.76, p=0.045), and absence of fever (3.95, 1.23-12.65, p=0.02).
Conclusion: Over 80% of patients undergoing cholecystectomy for biliary dyskinesia reported pain improvement. This study provides additional information on a combination of preoperative clinical characteristics and diagnostic test results that can be used to counsel patients and their families on the role of cholecystectomy in treating biliary dyskinesia.
