Biliary Dyskinesia in Children and Adolescents: A Mini Review

Biliary Disorders, Anomalies, and Malignancies in Children

Biliary abnormalities in children are uncommon, and the spectrum of biliary disorders is broader than in adult patients. Unlike in adults, biliary disorders in children are rarely neoplastic and are more commonly rhabdomyosarcoma rather than cholangiocarcinoma. Pediatric biliary disorders may be embryologic or congenital, such as anatomic gallbladder anomalies, anomalous pancreaticobiliary tracts, various cholestatic processes, congenital cystic lesions, or genetic conditions. They may also be benign, such as biliary filling anomalies, biliary motility disorders, and biliary inflammatory and infectious disorders. Distinguishing these entities with a single imaging modality is challenging. US is the primary imaging modality for initial evaluation of biliary abnormalities in children, due to its wide availability, lack of ionizing radiation, and low cost and because it requires no sedation. Other examinations such as MRI, CT, and nuclear medicine examinations may provide anatomic and functional information to narrow the diagnosis further. Hepatobiliary-specific contrast material with MRI can provide better assessment of biliary anatomy on delayed images than can traditional MRI contrast material. MR cholangiopancreatography (MRCP) allows visualization of the intra- and extrahepatic biliary ducts, which may not be possible with endoscopic retrograde cholangiopancreatography (ERCP). Suspected biliary atresia requires multiple modalities for diagnosis and timely treatment. Determining the type of choledochal cyst calls for a combination of initial US and MRCP. Many benign and malignant biliary masses require biopsy for definitive diagnosis. Knowledge of the imaging appearances of different pediatric biliary abnormalities is necessary for appropriate imaging workup, providing a diagnosis or differential diagnosis, and guiding appropriate management. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of "New Technologies"

BACKGROUND

In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children.

AIMS

This study aims to describe current indications and timing for LC in pediatric patients.

METHODS

Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020-2023.

RESULTS

In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores.

CONCLUSIONS

Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent.

Hypokinetic Biliary Dyskinesia in a Pediatric Patient: A Case Report

The diagnosis of biliary dyskinesia (BD) in pediatric patients lacks uniformity across the literature. BD is among the most common reasons for cholecystectomy in pediatric patients. Even still, diagnostic criteria for this disorder, including symptomatology and gallbladder ejection fraction, as well as the symptomatic relief after cholecystectomy, are inconsistent across the literature for the pediatric population. We share the case of an 18-year-old female patient who presented to our clinic for cholecystectomy for a diagnosis of BD. After 10 months of seeking a diagnosis, an eventual nuclear medicine HIDA scan revealed a biliary ejection fraction of 18%, leading her to our care. The patient underwent robotic-assisted laparoscopic cholecystectomy and tolerated the procedure well, reporting a resolution of symptoms on follow-up. The diagnosis and management of BD are complicated by the combination of vague and varied symptomatology and a lack of definitive, uniform diagnostic criteria in the pediatric population. Variability in diagnostic requirements varies between sources. While some look to the interpretation of gallbladder emptying studies, others rely on surgical outcomes. To further complicate diagnosis, some patients experience symptoms that do not correlate with their gallbladder emptying studies. The controversy extends beyond diagnosis as some studies argue against cholecystectomy as a treatment for BD, as it has been shown to not always resolve symptoms. More research should be conducted to identify and establish more consistent diagnostic criteria for BD in the pediatric population, as well as to study symptomatic improvement following cholecystectomy to establish optimal treatment for these patients. Biliary dyskinesia is a relatively common but rather inconsistent diagnosis in the pediatric population, and attention should be turned toward developing uniform and consistent diagnostic criteria in order to optimally recognize, diagnose, and treat these patients, ensuring a shorter time-to-diagnosis and improved quality of life.

Laparoscopic cholecystectomy in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the procedure of choice for the removal of gallbladder within the paediatric population. The aim of this study was to perform a systematic review and meta-analysis of the literature spanning the last 20 years to understand the indications for and safety of LCs in children.

METHODS

A comprehensive search of the published English language literature from January 2000 to June 2020 was done on PubMed, MEDLINE, and Google Scholar.

RESULTS

In total, 76,524 LC cases were identified from 114 studies. 78.9% of the patients were female and average age was 12 years old. Associated haematological disorders were identified in 16% of cases. The commonest indication for LC was cholelithiasis (68.4% in 66 studies), followed by cholecystitis (59.2% in 53 studies). Median operating time was 77 min. Median hospital stay was 2 days. The overall postoperative complication rate was 3.4% Major complications included bile duct injury (0.4%) and intra- or post-operative bleeding (0.9%). The conversion rate to open procedure was 2%. When comparing post-operative outcomes between emergency and elective admissions, three papers lent themselves to meta-analysis demonstrating no significant difference (p = 0.42). There was no statistically significant difference in postoperative complication rate between "hot" and "cold" laparoscopic cholecystectomies (p = 0.6).

CONCLUSION

This systematic review and meta-analysis is the largest collection of subjects on laparoscopic cholecystectomies in children. Laparoscopic cholecystectomy is a safe operation in children, with complication rates similar or comparable to the adult literature. Cholelithiasis, cholecystitis and biliary dyskinesia were the commonest indications for LC.