Abstract
Background: The impact of the age and sex adjusted body mass index (ISO-BMI) in the obese vs. non-obese children and adolescents with cholecystectomy for cholelithias is rarely reported. Patients and Methods: The national database was searched for cholecystectomies performed in paediatric patients between 1997 and 2011, and the 59 paediatric and adolescent patients having cholecystectomy in the Kuopio University Hospital district were divided in two groups by age and sex adjusted BMI (ISO-BMI) using the cut-off point of overweight (ISO-BMI 25 kg/m2) based on the Finnish growth standards. Results: Nationwide a total of 840 cholecystectomies were performed during the 15 years study period in Finland, most of which included females (77%), resulting in a mean of annual frequency of 4.8 (range: 3.9-6.1) procedures/100,000 population. In the study sample, most of the patients with the cholelithiasis were female (50/59, 85%). The gender distribution was equal among the younger patients, but among adolescents 6/52 (12%) of the patients with cholelithiasis were boys and 46/52 (88%) of the patients with cholelithiasis were girls. Obesity did not affect on operative parameters. The median operative time was 70 min (range, 30-155) and 66 min (44-130) in the high ISO-BMI–group. The recovery was similar in the two groups: the median length of hospital stay was 4 days in both groups. The patients in the low ISO-BMI-group vs. high ISO-BMI-group had a trend of higher serum bilirubin (p=0.16) and serum AFOS values (p=0.19). In the histological examination of the gallbladders 19/28 (68%) patients in the low ISO-BMI-group had inflammation vs. 26/31 (84%) patients in the high ISO-BMI-group (p=0.15). Conclusion: Our results between obese and non-obese children and adolescents with cholelithiasis are not statistically significant. The obese adolescents with female gender are in greater risk for cholelithiasis.
Obesity is common in children and adolescents in Western countries and in the past three decades in the United States the proportion of obese children has increased from 7 to 18% and that of adolescents from 5 to 18%, respectively (1). In Finland 12% of female adolescents and 22% of male adolescents are overweight, and 2% of female and 4% of male adolescents are obese, respectively (2). This is a concern because obesity is associated with some health problems; cardiovascular disease and metabolic disorders are mostly often recognized (2). Adult data indicate that being overweight or obese and being female are risks of gallstone and the impact of obesity on surgical outcome of cholecystectomy has been studied in adults, but the impact of overweight and obesity on surgical outcome of cholecystectomy in paediatric patients is rarely reported (3). The aim of the present study was first to evaluate the frequency of cholecystectomy at the national level, and second, to evaluate the impact of the age and sex adjusted body mass index (ISO-BMI) (2) in obese and non-obese children and adolescents with cholecystectomy. The study hypothesis was that the gallstone disease requiring cholecystectomy should be more common in obese adolescents than in their peers with normal body weight.
Patients and Methods
The study was approved by the Research Ethics Committee of the Hospital District of Northern Savo, Kuopio, Finland (Dnro 140/1997, Oct 17, 1997) and conducted in accordance with the Declaration of Helsinki. The cholecystectomies performed in children and adolescent between January 1st 1996 and May 31st 2013 in Kuopio University Hospital (KUH) region with a catchment area of 46,000 children aged 0 to 11 years and 35,000 adolescent aged 12 to 18 years were reviewed.
All cholecystectomies (n=59) were performed by expert surgeons. A standardized four-trocar technique (two 10 mm and two 5 mm trocars) was used in laparoscopic cholecystectomy (LC, n=51). A 12-mmHg pneumoperitoneum (CO2) was created using a veress needle (4). Open cholecystectomy (OC, n=8) was performed with a standard technique. No routine cholangiography was performed. Endotracheal anaesthesia and post-operative care were standardized and similar in the two groups.
The surgeon evaluated macroscopically the gallbladder and recorded stones and signs of acute, sub-acute or chronic inflammation of the gallbladder. A histopathological examination was performed for all gallbladder samples. The criteria for chronic inflammation were a thick-walled gallbladder in surgeons' evaluation and signs of a severe chronic inflammation in the histological examination.
Impact of body weight. To evaluate the impact of body weight on outcome and need for cholecystectomy patients were divided in two groups by ISO-BMI using the cut-off point of overweight (ISO-BMI 25 kg/m2) based on the standard by Saari et al. (2). There were 28 patients with a low ISO-BMI (<25 kg/m2) and 31 patients with high ISO-BMI (≥25 kg/m2).
The national data of cholecystectomies performed in paediatric patients between January 1st 1997 and December 31st 2011 was gathered from the Care Registry for Health Institutions, kept by the National Institute for Health and Welfare (THL). Data on all hospital inpatient treatments and surgical procedures performed in all Finnish hospitals is submitted annually to THL. The data include patients' age and sex, treatment period, date of surgical procedure and codes for surgical procedures according to the NOMESCO Classification of Surgical Procedures (NSCP) (5); procedure codes search for; JKA20, OC=open cholecystectomy and JKA21, LC=laparoscopic cholecystectomy. The mean number of children in Finland aged under 12 years was 715,000 and that of adolescent (12 to 18 years old) 453,000 during the study period.
Statistics. Data was entered and statistical analyses were performed according to analysis plan using the SPSS package (IBM SPSS statistics 19, IBM, Somerset, USA). Mann-Whitney U-test, Pearson Chi-square-test and Fisher's Exact-test were used for statistical comparisons. A two-sided p-value of 0.05 or less was considered statistically significant. Data are presented as mean (standard deviation, SD), median [minimum-maximum] or number of cases (%), as appropriate.
Results
In Finland, a total of 840 cholecystectomies, (LC=737 and OC=103) were performed between 1997 and 2011 in children and in adolescents. Children (age <12 years) had 89 operations and adolescents (age 12-18 years) 751 cholecystectomies. Most of the cholecystectomies were performed for females (n=648, of which 588 were LCs and 60 OCs). Males had 149 LCs and 43 OCs during the 15 years study period. The mean of annual frequency of paediatric cholecystectomy was 4.8 (range= 3.9-6.1) procedures/100,000 population, and that among children 0.5 (0.3-1.7) procedures/ 100,000 population and among adolescent 11.1 (8.2-14.8) procedures/100,000 population (Figure 1).
Data from paediatric patients operated in the KUH district (n=59) were analyzed to evaluate whether obesity had impact on the need and outcome of cholecystectomy. Altogether 28/59 (48%) patients had a low ISO-BMI (<25 kg/m2) and 31/59 (52%) patients a high ISO-BMI (≥25 kg/m2). The baseline demographic characteristics of the two groups and surgical data are shown in Table I. Seven patients (7/59, 12%) were children (2-11 years), and 52/59 (88%) patients were adolescents (12-18 years). In the low ISO-BMI–group three patients were underweight, ISO-BMI (<18 kg/m2); one 4-year-old prematurely born girl had ISO-BMI of 11.5 kg/m2 and two other patients 17.5 and 17.9 kg/m2, respectively. In the high ISO-BMI-group 17 patients were overweight (ISO-BMI 25-29.9 kg/m2) and 14 patients obese (ISO-BMI ≥30 kg/m2). The two 18 years old obese girls had a severe obesity with ISO-BMI of 36.0 and 38.9 kg/m2, respectively.
Most patients with the cholelithiasis were females (50/59, 85%). The gender distribution was equal among younger patients, out of the 7 children; there were 3 (43%) boys and 4 (57%) girls. After puberty there was a female dominance, among adolescent 6/52 (12%) were boys and 46/52 (88%) were girls. Five boys had a normal ISO-BMI, 2 were overweight and 2 obese. Among girls, 3 had ISO-BMI <18 kg/m2, 20/50 (40%) had normal ISO-BMI, 15/50 (30%) were overweight and 12/50 (24%) were obese.
Obesity did not affect the operative parameters. The median of operative time was 70 min (range: 30-155) and 66 min (range: 44-130) in the high ISO-BMI–group. The recovery was similar in the two groups: the median length of hospital stay was 4 days in both groups. The patients in the low ISO-BMI-group vs. high ISO-BMI-group had a trend of higher serum bilirubin (p=0.16) and serum AFOS values (p=0.19). In the histological examination of the gallbladders 19/28 (68%) patients in the low ISO-BMI-group had inflammation vs. 26/31 (84%) patients in the high ISO-BMI-group (p=0.15). In the comparison between the no-inflammation and the inflammation-group, there was a trend of higher serum AFOS values (mean (SD)) in the no-inflammation-group (273 (197)) U/l, vs. the inflammation-group, (183 (154)) U/l (p=0.16) as well as lower serum bilirubin values in the no-inflammation, (19 (13) μmol/l vs. inflammation–group, 18 (22) μmol/l (p=0.83).
Discussion
The above data indicate that cholecystectomy in children is an uncommon procedure in Finland, with a similar distribution among boys and girls under the age of 12 years, however, after the puberty (>12 years) the number of cholecystectomies is increasing in parallel to the age of the patients. Moreover, data from the KUH region indicate that obesity is a risk factor contributing to cholecystectomy. In Finland 12% of female adolescents and 22% of male adolescent are overweight (2), but the proportion of the overweight subjects among adolescents having cholecystectomy is significantly higher. Three of six (50%) male adolescents were overweight and 27/46 (59%) of the female adolescents had ISO-BMI 25 kg/m2 or higher, respectively. The rate of the cholecystectomies in children is similar to that reported in USA (6), but 2-times higher than in UK (7), respectively. Most of the cholecystectomies were laparoscopic and no conversions were reported. LC has proven to be safe and efficient procedure for cholelithiasis in children and adolescents regardless of obesity also reducing the number of overnight stays (3, 8, 9).
Nationwide cholecystectomy rates among the children, aged 0 to 11 years, and the adolescents, aged 12 to 18 years, in Finland between 1997 and 2011. a: The annual rates of open and laparoscopic cholecystectomies; b: the annual rates of cholecystectomies in males and females; c: the sex distribution among children; d: the sex distribution among adolescents having cholecystectomy.
Patients' demographics and surgical data according to patients' age and sex adjusted body mass index (ISO-BMI). Data are mean (SD), median [minimum-maximum], or number of cases (%).
The cholecystectomy rates are increasing with age with many risk factors including the hemolytic disorders, family history of gallstones, IgA deficiency, cystic fibrosis, therapy with ceftriaxone and the Gilbert's disease (8, 9, 10, 11, 12). Recent studies show that the proportion of cholecystectomies performed without a diagnosis of haemolytic anaemia has doubled nationwide which corresponds to the rise in childhood obesity (3).
In 2000 Cole et al. (13) introduced ISO-BMI as a standard definition for child overweight and obesity, as well as to provide internationally-comparable prevalence rates of overweight and obesity in children. In Scandinavia Holmbäck et al. (14) and Sola et al. (15) proposed the cut off points, which are based on Cole et al. ISO-BMI classification. In 2011, Saari et al. introduced new Finnish growth references for children and adolescent for assessment of length/height-for-age, weight-for-length/height, and body mass index-for-age (ISO-BMI) which unlike most of the Western countries has not been available to the Finnish population before (2).
Obesity is a complicating factor for the surgeon and it has been shown to increase operative time, time in the operation theatre, number of overnight stays and post-surgical infections in adults (16). Although there is an increase in obesity of children and adolescents, the impact of obesity on LC and its complications in paediatric population are not well-documented (3, 8) but indicate that LC in obese children as well as adults proves to be beneficial. Our study had similar results compared to Garey et al. (3) for there were no statistically significant differences in operative time or number of overnight stays in the high ISO-BMI-group compare to that in the low ISO-BMI-group.
In conclusion, we are unable to show any significant differences in the perioperative parameters between the low ISO-BMI vs. high-ISO-BMI-group in the obese and non-obese children and adolescent with cholelithiasis. However, the obese adolescents with female gender are greater in risk for cholelithiasis.
Footnotes
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Conflicts of Interest
Authors have no conflicts of interest and they have full control of all primary data. Authors allow the journal to review the data if requested.
- Received December 16, 2013.
- Revision received March 28, 2014.
- Accepted March 29, 2014.
- Copyright © 2014 The Author(s). Published by the International Institute of Anticancer Research.
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