Introduction

Laparoscopic cholecystectomy (LC) is currently considered the standard of care for managing gallstone disease. The worldwide acceptance of LC is mainly due to lower postoperative wound complaints, faster recovery, better postoperative cosmetic results, shorter hospital stay, and earlier return to work. Although numerous studies have been published addressing both the advantages and complications of LC in acute cholecystitis, there is still limited information concerning the safety and efficacy of LC in the management of acute cholecystitis for sickle cell disease (SCD) pediatric patients, and controversies remain unresolved.

Subjects and Methods

This is a retrospective study, where patients operated at a single large volume center between August 2007 to August 2020 were evaluated. These were identified from clinical records, and their medical files were examined. Patients aged 3–12 years with calculi causing an acoustic shadow in the gall bladder determined at ultrasonography were included in the study. Patients were evaluated in terms of age, sex, presentation symptoms, body mass index, accompanying diseases, family history of gallstones, history of prolonged drug use, laboratory tests, ultrasonographic findings and results. Complete blood count, reticulocyte, peripheral smear, direct Coombs, osmotic fragility, transaminases, γ-glutamyl transferase, total protein, albumin, total-direct bilirubin, and lipid profile results for etiology were recorded from the file. Intra operative findings and post-operative complications were noted from clinical case records.

Results

Total 309 patients presented to us with diagnosis of GB calculi based on USG examination out of which 253 patients underwent laparoscopic cholecystectomy between August 2007 and August 2020. Three patients were converted to open due to intra operative complications and were removed from the final analysis. One child had bleeding which was converted to open and other two had difficulty in identification of anatomical landmarks so were converted to open. Age distribution was 3 years to 12 years. There was no significant difference between number of male & female children, pain abdomen was most common feature as a clinical presentation (n=180), other presentation was jaundice(n=2) and nausea (n=15). Children were evaluated to know the cause of GB calculi and we found that hemolytic anemia was present in 10 patients. [Table 1] Twenty-five patients were obese with BMI > 2SD. Standard 4 port laparoscopic cholecystectomy was done in all the patients. Stone was replaced by sludge in 32 cases, 22 cases has single stone & rest had multiple stone. Duration of surgery was 30 minutes to 45 minutes with median of 35 minutes. Two patients out of 250 had CBD injury and were managed by open roux en-Y hepatico-jejunostomy in the same admission. All patients who underwent uneventful laparoscopic cholecystectomy were discharged within 7 days of surgery.

Discussion

The epidemiology of cholelithiasis in children has been less explored and still has un-answered questions. Cholelithiasis was considered to be uncommon in young infants and small children but have been increasingly diagnosed in recent years due to wide- spread use of ultrasonography.^[1] However, there is not much of information from India and no consensus among Indian pediatricians and pediatric surgeons regarding management of gallstones in children. The sex ratio of cholelithiasis was equal. Only in the adolescent group (14–18 years) was there a female predilection for gallstones. This may correspond with the time at which cholesterol saturation in bile increases, preceding the development of cholesterol-related gallstones.^[2,3] Obesity, ileal disease, and a family history of childhood gallstones are factors associated with cholelithiasis in elderly children. Similar to the influence of puberty in female adolescents, obesity, ileal disease and a family history are known risk factors for development of cholesterol-related gallstones in adolescence. In contrast to other reports, chronic hemolysis was not the most common predisposing factor for cholelithiasis in our series. This probably explains why gallstones found in children are predominantly mixed stones. Feeding by TPN as a risk factor for biliary stones was not noted in this study. Only 4% of our patients had hemolytic disease related gallstones, which is less than described in previous reports. ^[4,5]

A number of studies have examined the role of defective gallbladder motility (that is, increased fasting and postprandial gallbladder volumes and slower postprandial emptying in response to meal) as a major risk factor for cholesterol gallstone formation. Indeed, intraluminal gallbladder stasis provides a sufficiently prolonged time for nucleation of excess biliary cholesterol and gallstone growth but is this mechanism of gall stone formation the primary pathophysiology behind the gall stone disease in children is a matter of further study.

In this present study the total stay in the hospital was comparable to the other adult studies and the complication rate was also not high. Since this is a retrospective study done in children presenting to a surgical facility, the prevalence of gall stone disease in children with hemolytic anemia can not be extrapolated; however, we do want to emphasize that the incidence of gall stone disease in patients with hemolytic anemia is quite low in Indian population as compared to the available literature.

Conclusion

Gall stone disease is increasingly common in patient presenting with repeated pain abdomen. Hemolytic anemia is not a common cause of pediatric gall stone disease. Laparoscopy is well tolerated in children with very few complications in experienced hands.