National Trends in Interventions for Pediatric Gallstone Pancreatitis

Introduction

Acute pancreatitis is not common in the pediatric population occurring at a rate of 3–13 cases per 100,000 children per year, but the incidence has been increasing over the last decade.^1–5 The most common etiology of acute pancreatitis in children is biliary disease, such as gallstones or microlithiasis, accounting for up to 30% of all cases.^1,6

In the adult population, patients who presented with acute gallstone pancreatitis had a risk of recurrence up to 11.1% in those who underwent only endoscopic retrograde cholangiopancreatography (ERCP) and up to 22.7% for those who had no intervention. ⁷ Therefore, in adults who present with mild, self-limited gallstone pancreatitis, the recommendation is to undergo cholecystectomy during the same hospitalization to prevent recurrent episodes.^8–10

Laparoscopic cholecystectomy (LC) during index hospitalization for the pediatric population is not as well-studied as in adults, but the literature in the pediatric population is in concordance with the adult literature in that there are high recurrence rates of gallstone pancreatitis without cholecystectomy. A single-center study in pediatric patients by Badru et al. found a gallstone pancreatitis recurrence rate of 31% for patients who did not undergo cholecystectomy during index hospitalization. ³ Another more recent study out of the United Kingdom found an absolute risk reduction of 57.5% for readmission for gallstone pancreatitis if pediatric patients underwent cholecystectomy within 2 weeks of diagnosis. ⁴ The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Pancreas Committee released guidelines in 2018 recommending cholecystectomy before discharge in pediatric patients with mild, acute gallstone pancreatitis. ¹¹

The objective of this study was to describe the use of LC and/or ERCP during index hospitalization for gallstone pancreatitis over time. In addition, we aimed to evaluate factors associated with the timing of LC and/or ERCP during index hospitalization over time.

Materials and Methods

Results

Rates of procedures over time

From 2000 to 2019, the rate of LC during index hospitalization ranged from 55.4% to 63.8% with no statistically significant trend over time (P = .76). The rate of ERCP alone decreased from 24.8% in 2000 to 14.0% in 2019, but was not statistically significant (P = .23). The rate of undergoing both an ERCP and LC decreased from 19.0% in 2000 to 8.5% in 2019, but was also not statistically significant (P = .13; Fig. 1).

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FIG. 1.

Rates of intervention .(LC, ERCP, or both) during the index hospitalization for gallstone pancreatitis over time. ERCP, endoscopic retrograde cholangiopancreatography; LC, laparoscopic cholecystectomy.

Features associated with undergoing LC or ERCP

Patients had higher odds of undergoing LC if they were female (odds ratio: 1.33 [95% confidence interval: 1.16–1.52]) compared to male. Patients also had higher odds of undergoing LC if they were older in age (1.10 [1.08–1.12]). There were lower odds of undergoing LC in the Northeast (0.71 [0.59–0.85]) or Midwest (0.76 [0.64–0.90]) compared to the West. Patients also had lower odds of undergoing LC in rural nonteaching hospitals (0.76 [0.61–0.94]) compared to urban teaching hospitals, or if they were treated at a small (0.72 [0.60–0.86]) compared to a large hospital. Finally, patients had lower odds of LC if they had private insurance (0.87 [0.76–098]) compared to public insurance (Fig. 2a).

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FIG. 2.

Multivariable logistic regressions evaluating the odds of undergoing (a) LC, (b) ERCP, (c) both LC and ERCP, or (d) no procedure during index hospitalization based on sex, age, hospital region, type, and insurance status. Reference groups are male, west, large bedsize, urban teaching, and public insurance. ERCP, endoscopic retrograde cholangiopancreatography; LC, laparoscopic cholecystectomy.

Patients had lower odds of undergoing ERCP if they were treated at a rural nonteaching hospital (0.45 [0.32–0.62]) compared to urban teaching hospitals, or if they were treated at a small (0.41 [0.31–0.55]) or medium (0.79 [0.67–0.94]) hospital compared a large hospital (Fig. 2b).

There were higher odds of undergoing both LC and ERCP if the patient was older in age (1.09 [1.06–1.13]). There were lower odds of undergoing both LC and ERCP if patients were treated at a rural nonteaching hospital (0.42 [0.28–0.63]) compared to an urban teaching hospital or small hospital (0.39 [0.27–0.54]) compared to a large hospital (Fig. 2c).

Patients had lower odds of undergoing no procedure if they were female (0.73 [0.64–0.84]) compared to male. Patients also had lower odds of no procedure if they were younger in age (0.93 [0.91–0.95]). There were higher odds of undergoing no procedure if the patient was treated in the Northeast (1.42 [1.18–1.72]) or Midwest (1.35 [1.14–1.62]) compared to the West. Patients also had higher odds of no procedure in rural nonteaching hospitals (1.49 [1.19–1.86]) compared to urban teaching hospitals and at small hospitals (1.60 [1.33–1.93]) compared to large hospitals. Finally, patients had higher odds of no procedure if they had private insurance (1.18 [1.03–1.34]) compared to public insurance (Fig. 2d).

Discussion

Our study shows that the rate of LC for gallstone pancreatitis during index hospitalization has not changed over the last two decades. The rates of ERCP alone or both LC and ERCP have been decreasing over time, however, this was not a statistically significant trend. When LC or ERCP were performed, they occurred earlier in the hospital stay, and this trend was significant. Overall, LOS has decreased for all patients, however, the trend of decreased LOS over time was significant for patients undergoing either LC or ERCP but was not significant for patients who had neither of these interventions.

Finally, we found that females as compared to males, and patients older in age, were more likely to undergo LC during index hospitalization. Patients were less likely to undergo LC during index hospitalization if they lived in the Northeast or Midwest compared to the West, or if they were treated at a rural nonteaching hospital compared to an urban teaching hospital or small compared to large hospital. In addition, patients with private insurance compared to public were less likely to have a LC during index hospitalization.

Our study showed that 46% of patients underwent LC during the index hospitalization, which was similar to a single-center study in pediatric patients that reported a rate of 39.6%. ³ In comparison, a study out of the United Kingdom of 670 pediatric patients admitted with gallstone pancreatitis found a lower rate of LC during index hospitalization at 11.8%. ⁴ The rate of LC within 2 weeks of diagnosis was 26%, but overall, 20.3% of patients never had a LC. However, in that study, half of the patients who never had a LC did undergo ERCP, meaning only 10% of patients had no intervention. ⁴

Our study found that 35.5% of patients had no intervention for their gallstone pancreatitis, but this is difficult to compare to the 10% from the United Kingdom study because they had a median follow-up time of about 6 years, while we only evaluated the index hospitalization. The recommendation from NASPGHAN to perform LC during index hospitalization in the pediatric population was released toward the end of our study period, but the rate of LC during index hospitalization for gallstone pancreatitis has been stable for two decades. As more literature is published describing the benefits of LC during index hospitalization, we hope this will lead to more provider awareness and may improve timely management of children with gallstone pancreatitis.

As for ERCP, NASPGHAN reported that it is indicated for biliary pancreatitis but depends on local expertise. ¹¹ Per published literature, ERCP alone is not sufficient in preventing recurrent gallstone pancreatitis.^3,4 Our study shows low rates of ERCP utilization overall, which could be related to lack of pediatric expertise available, or the knowledge that treating gallstone pancreatitis with ERCP alone is not sufficient. However, the retrospective nature of this study only allows speculation on why ERCP is not common.

Multiple studies from the adult literature have shown that early cholecystectomy, typically within 48–72 hours of admission, leads to a significantly shorter LOS.^13–17 Our findings in the pediatric population are congruent with the adult literature as we found that LC is occurring significantly earlier during the index hospitalization and there is a significant decrease in the trend of LOS over time. In addition to shorter LOS, the adult literature describes lower rates of ERCP usage when early cholecystectomy is performed.^14,16 While the trend was not statistically significant, there was a decrease in the overall rate of ERCP use over time in our study. If these findings are similar to the adult literature, maybe the decreasing rate of ERCP use is related to the trend in earlier cholecystectomy.

Similar to our study, Blundell et al. found that adult females were more likely to undergo LC during index hospitalization for gallstone pancreatitis compared to males. ¹⁸ This study also found that patients with private insurance were less likely to undergo LC during index hospitalization. ¹⁸ This is congruent with our findings but may not be comparable as the Blundell et al. study was performed in Australia where there is universal health care with the option of private insurance coverage. In that setting, patients with private insurance may initially be treated at a public hospital but choose to have an interval LC at a private hospital. In addition, they found that patients were less likely to undergo index LC if they were treated at a low or medium volume hospital. ¹⁸

Although not a perfect comparison to our study as they looked at surgical volume rather than bedsize, this is in agreement with our findings and likely related to smaller hospitals having fewer resources and less access to surgeons. Another retrospective study by Chouairi et al. used the Nationwide Inpatient Sample Database and looked at patients undergoing LC during index hospitalization after having an ERCP for gallstone pancreatitis. ¹⁹ They also found that females were more likely to undergo LC. In contrast to our study, they found that patients younger in age were more likely to undergo LC. ¹⁹ However, this study was in the adult population, so the younger patients are likely similar to the adolescents in our study. In the adult population, the lower likelihood of undergoing LC as patients get older may be associated with higher rates of comorbidities.

Moreover, this study found that index hospitalization LC was less likely at urban teaching hospitals, which is the opposite of what we found. For adults, urban teaching hospitals may be more likely to see higher acuity patients with more comorbidities who are not great candidates for surgery during index hospitalization. For children, urban teaching hospitals are more likely to be tertiary care centers with greater access to pediatric surgery than rural nonteaching hospitals. Finally, our study found disparities in index LC based on geographic location. This indicates that practice patterns vary based on factors not related to patients' health conditions.

Our study is not without limitations. First, this was a retrospective study using a large administrative database, which inherently has limitations such as missing data and the inability to account for clinical decision making. Second, as this is an administrative database, it is difficult to elucidate if the gallstone pancreatitis was mild or severe that could influence the decision to perform an index versus interval cholecystectomy. Third, ERCP data may not be fully captured, therefore rates of ERCP may be underestimated. For example, at our freestanding children's hospital, there are no pediatric interventional gastroenterologists who perform ERCP, and our patients must be transferred across the street to the adult hospital for ERCP and transferred back to the children's hospital for cholecystectomy. The ERCP performed at the adult hospital may not be uniformly captured by all sites contributing data in this administrative database.

Finally, as KID is a sampling of pediatric discharges every 3 years, we could not evaluate rates of recurrent gallstone pancreatitis in those who did not undergo index cholecystectomy or ERCP.

Conclusions

The proportion of LC performed during index hospitalizations for children with gallstone pancreatitis has been stable for two decades. However, trends indicate that among those who undergo either LC or ERCP, interventions are occurring earlier in the hospital stay and LOS is becoming shorter. Focused efforts, including surgical provider education, may improve timely management for children with gallstone pancreatitis.