Complications of Pediatric Cholecystectomy: Impact from Hospital Experience and Use of Cholangiography Lorraine I Kelley-Quon, MD, MSHS, Adrian Dokey, Stephen B Shew, MD, FACS

MD,

Howard C Jen,

MD, MSHS,

Complications after cholecystectomy in children are poorly characterized. The aim of this study was to assess risk factors for major surgical complications for children undergoing cholecystectomy. STUDY DESIGN: All children 4 to 18 years old with gallbladder disease who underwent cholecystectomy from 1999 to 2006 were identified from the California Patient Discharge Database. Patient, hospital, and surgical factors were analyzed using multivariate logistic regression analysis to identify factors predictive of bile duct injury (BDI) and postoperative ERCP. RESULTS: A cohort of 6,931 children treated at 360 hospitals was evaluated. Most children underwent cholecystectomy at a non-children’s hospital (84%). Intraoperative cholangiogram (IOC) was performed in 2,053 (30%) children. Of 5,101 children tracked through the year after cholecystectomy, 153 (3%) required readmission for surgical complications. Bile duct injury occurred in 25 (0.36%) children, and postoperative ERCP was performed in 711 (10%) children. Older age (odds ratio ¼ 0.80; 99% CI, 0.670.95) was associated with decreased risk of BDI. Increased hospital tendency for routine IOC use was associated with increased likelihood of BDI (odds ratio ¼ 12.92; 99% CI, 1.31127.15). Receiving surgical care at a children’s hospital was associated with a decreased likelihood of postoperative ERCP (odds ratio ¼ 0.39; 99% CI, 0.230.66). As anticipated, choledocholithiasis, cholecystitis, IOC, and laparoscopic cholecystectomy were associated with increased risk of postoperative ERCP (p < 0.01). CONCLUSIONS: Serious complications and readmissions from pediatric cholecystectomy are uncommon. Surgeons performing cholecystectomy in young children must have an elevated concern about BDI. Routine IOC or surgical volume might not be helpful in lowering BDI rates. (J Am Coll Surg 2014;218:73e81.  2014 by the American College of Surgeons)

BACKGROUND:

Laparoscopic cholecystectomy has become the preferred technique for treatment of pediatric gallbladder disease during the past 10 to 15 years. However, complications after laparoscopic cholecystectomy in children have not been clearly characterized. Bile duct injuries (BDI) from laparoscopic cholecystectomy in adults have been well described, with a reported incidence of 0.2% to 0.5%.1 Although uncommon, BDIs result in a substantial potential for morbidity and mortality for patients,2 and are one of the most common reasons for malpractice claims against surgeons.3 Earlier studies in adults revealed that routine use of intraoperative cholangiogram (IOC) and greater surgical case volume experience were related to decreased likelihood of BDI.1-6 In contrast, little has been published about postoperative complications for children who undergo laparoscopic cholecystectomy.7 Recently, Raval and colleagues’ review of the Kids’ Inpatient Database reported the national experience of laparoscopic cholecystectomy in children

CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Dr Kelley-Quon is supported by the Robert Wood Johnson Foundation. Dr Shew is supported in part by NIH grant HD052885. The Robert Wood Johnson Foundation had no role in the preparation, review, or approval of the manuscript. Received October 3, 2012; Revised September 19, 2013; Accepted September 30, 2013. From the Division of Pediatric Surgery, Department of Surgery, Mattel Children’s Hospital (Kelley-Quon, Jen, Shew), Robert Wood Johnson Foundation Clinical Scholars, Division of General Internal Medicine and Health Services Research (Kelley-Quon), David Geffen School of Medicine at UCLA, Los Angeles, CA, and Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD (Dokey). Correspondence address: Stephen B Shew, MD, FACS, Division of Pediatric Surgery, Department of Surgery, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, CHS Bldg, MC 709818, Los Angeles, CA 90095-7098. email: sshew@mednet. ucla.edu

ª 2014 by the American College of Surgeons Published by Elsevier Inc.

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ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.09.018

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Complications of Pediatric Cholecystectomy

Abbreviations and Acronyms

BDI CaPDD IOC LOS OR

¼ ¼ ¼ ¼ ¼

bile duct injury California Patient Discharge Database intraoperative cholangiogram length of stay odds ratio

and characterized the patient and hospital factors associated with BDI.8 Although they presented the first large study categorizing BDI in children, it did not explore the influence of factors previously validated in the adult literature to impact BDI. In addition, this study did not examine factors related to the additional health care resources required after cholecystectomy, such as use of ERCP for choledocholithiasis and other surgical complications requiring readmission. The current study was undertaken to determine the incidence of, and risk factors for, BDI and use of postoperative ERCP in children undergoing laparoscopic cholecystectomy in California. In addition, clinical factors associated with decreased rates of complications (eg, IOC) and hospital-level factors (eg, surgical case volume and specialty type) were examined. Finally, postoperative complications during the operative admission and subsequent readmissions were also analyzed.

METHODS This retrospective cohort study was performed after obtaining IRB approvals from the University of California, Los Angeles and the California Office of Statewide Health Planning Development. Data were obtained from the California Patient Discharge Database (CaPDD). The CaPDD collects annual data on all inpatients discharged from non-federal hospitals licensed in California. A discharge abstract is reported for each inpatient hospitalization and includes patient demographics, admission and discharge details, and ICD-9 diagnosis and procedure codes.9 The Office of Statewide Health Planning Development internally validates individual records in the CaPDD through 9 levels of checkpoints, with an error tolerance level of 7 cholecystectomies per year (75th percentile) and low-volume hospitals performing

Complications of pediatric cholecystectomy: impact from hospital experience and use of cholangiography.

Complications after cholecystectomy in children are poorly characterized. The aim of this study was to assess risk factors for major surgical complica...
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