Early Cholecystectomy in Children with Gallstone Pancreatitis Reduces Readmissions David J. Wilkinson, Nisarg Mehta, Iain Hennessey, David Edgar, Simon E. Kenny PII: DOI: Reference:
S0022-3468(15)00284-5 doi: 10.1016/j.jpedsurg.2015.04.011 YJPSU 57221
To appear in:
Journal of Pediatric Surgery
Received date: Revised date: Accepted date:
16 September 2014 19 March 2015 19 April 2015
Please cite this article as: Wilkinson David J., Mehta Nisarg, Hennessey Iain, Edgar David, Kenny Simon E., Early Cholecystectomy in Children with Gallstone Pancreatitis Reduces Readmissions, Journal of Pediatric Surgery (2015), doi: 10.1016/j.jpedsurg.2015.04.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT EARLY CHOLECYSTECTOMY IN CHILDREN WITH GALLSTONE PANCREATITIS REDUCES READMISSIONS
T
Authors: David J Wilkinson1,2, Nisarg Mehta3, Iain Hennessey1, David Edgar4, Simon E Kenny1,2
RI P
Institutions:
SC
1. Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
Liverpool, Eaton Road, Liverpool, L12 2AP, UK
NU
2. Reproductive and Developmental Medicine, Institute of Child Health, University of
MA
3. University of Liverpool Medical School, Cedar House, Ashton Street, Liverpool L69 3GE,
ED
UK
CE
Street, Liverpool L69 3GE, UK
PT
4. Cellular and Molecular Physiology, University of Liverpool, Sherrington Building, Ashton
Corresponding author:
AC
Mr Simon E Kenny
Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK Phone: 0151 2525434 Fax: 01512525677 Email: [email protected]
ACCEPTED MANUSCRIPT Abstract Background: Multiple guidelines exist in adult practice regarding the timing of
T
cholecystectomy for gallstone pancreatitis. Current evidence to support their
RI P
application to paediatric practice is minimal. This study sought to determine the effect
SC
of timing of cholecystectomy for gallstone pancreatitis in children on the risk of
NU
readmission
Method: All patients under 19 years of age presenting to an acute NHS trust in
MA
England with a diagnosis of gallstone pancreatitis between 1 January 1999 and 31 st
ED
December 2009 were included. Patient level data were extracted from the English
PT
Hospital Episode Statistic Database. ICD10, OPCS4.6 and hospital administrative
CE
data were used to determine: diagnosis, age, associated comorbidities and subsequent procedures performed.
AC
Results: 670 cases of gallstone related pancreatitis were recorded in under 19 year olds between 1999 and 2009 resulting in 3 deaths during this period. The majority (534/670) underwent a cholecystectomy which was performed less than two weeks from primary admission in 33% (174/534) of cases. Cholecystectomy within two weeks provides an actual risk reduction (ARR) of readmission of 57.5% (95%CI 50.1 to 64.4%, p0.05). Conclusions
ACCEPTED MANUSCRIPT Readmissions can be significantly reduced in this population by performing a cholecystectomy within two weeks with no apparent rise in surgical complications.
AC
CE
PT
ED
MA
NU
SC
RI P
T
Key Words: Gallstone pancreatitis; Pediatrics; Outcomes; Cholecystectomy
ACCEPTED MANUSCRIPT 1. Introduction Acute gallstone related pancreatitis (GRP) is rare in children; however, in the last decade there has
RI P
T
been a rise in incidence in children paralleling an increase in obesity.[1-4] Between 5.4-32.6% of cases of childhood pancreatitis are reportedly due to GRP.[2 3] Although GRP
SC
in children is usually mild, the incidence of recurrent episodes prior to cholecystectomy is high (25 60%),[5 6] and can be associated with both significant morbidity and mortality.[7 8] UK adult
NU
guidelines were published in 2005 recommending that cholecystectomy be performed in all patients
MA
no later than two-weeks after initial presentation and these guidelines have subsequently been validated by several studies.[9 -12] These guidelines were intended for adults, and the evidence as to
ED
the applicability of this guideline to children with GRP largely limited to small single institution retrospective case series.[13-15]. Of these the most significant study is that of Knott, et al, who
PT
reported a 36.8% recurrence rate of GRP associated with a delayed cholecystectomy, which could be
CE
prevented by operating within the index admission.
In their series of 22 children early
AC
cholecystectomy performed within the index admission was not associated with an increase in complications. [13]
The aim of this study was to determine the incidence and trends in admissions for gallstone pancreatitis in children at a population level between 1999 and 2009, and specifically to assess the applicability of the existing adult guideline for cholecystectomy within two weeks of presentation.
ACCEPTED MANUSCRIPT 2. Methods In order to counter the inherent problems caused by small sample size in the analysis of outcomes of
T
such surgical studies in children, we utilised the Hospital Episode Statistics (HES) database, a national
RI P
clinical data repository in England collated by the UK Department of Health, in which all patient episodes are individually recorded, detailing both administrative and clinical data. Each episode is
SC
linked via a unique patient identifier, allowing the patient to be tracked between institutions.
NU
For the purpose of this study we defined our paediatric population as all children under the age of 19
MA
years, this age limit was chosen firstly as there is very little published data on 16 to 18 year old children, with the majority of current studies limited to patients above this age. More importantly
ED
there is wide variety in the provision of medical care to the under 19 population, with a number of children in the 16-18year old bracket still receiving their definitive surgery in specialist paediatric
PT
centres. Treatment for GRP is provided by paediatricians, paediatric surgeons or surgeons with a
CE
predominant adult practice, with significant variation seen in the boundaries between paediatric and
AC
adult services in different geographical regions. Furthermore, there is often a lag period between the first episode of GRP and the subsequent cholecystectomy resulting in a number of episodes straddling the transition between paediatric and adult services. All cases of GRP in under 19 year olds presenting to secondary care providers between 1999 and 2009 were identified from the HES database, using the International Classification of Diseases, 10th revision (ICD10) diagnosis code for gallstone disease and pancreatitis (K800, K801, K802, K803, K805, K806, K807, K808, K809 & K85). Patients undergoing a cholecystectomy were identified using the Office of Population, Census & Surveys - Classification of Surgical Operations and Procedures, Fourth Revised Criteria (OPCS 4.6) codes for cholecystectomy (J181, J182 & J183). Population estimates for the under 16 and 18 year old populations were obtained from the UK National Statistics Authority.[16] Approval
ACCEPTED MANUSCRIPT for the use of HES data was obtained as part of the standard HES application process. Specific research ethic committee approval was not required as the study was limited to the analysis of a pre-
T
existing anonymised dataset.
RI P
The data were analysed to determine timing of cholecystectomy following the primary GRP related admission, subsequent readmissions either with recurrent episodes of pancreatitis or post-operative
SC
complications, and administrative and demographic data. Cases were then sub-grouped according to:
NU
the timing of cholecystectomy following initial presentation (2weeks) and age (0-16 years, 17-18 years). In order to identify post-operative complications, every subsequent admission for
MA
each case identified was individually analysed and complications recorded. For example, all cases of recurrent pancreatitis, retained stones and formation of pancreatic pseudocysts were identified
PT
cholecystectomy were excluded.
ED
based on both ICD and OPCS coding data. In addition, readmissions apparently unrelated to GRP and
CE
Statistical analyses were performed using GraphPad Prism Version 5 (GraphPad Software Inc.
AC
California, USA). Absolute risk reduction and Fisher’s exact test was used for independent categorical data and Mann-U Whitney for continuous non-parametric data. Correlation was assessed using Spearman’s Rank analysis. Statistical significance was set at p
S0022-3468(15)00284-5 doi: 10.1016/j.jpedsurg.2015.04.011 YJPSU 57221
To appear in:
Journal of Pediatric Surgery
Received date: Revised date: Accepted date:
16 September 2014 19 March 2015 19 April 2015
Please cite this article as: Wilkinson David J., Mehta Nisarg, Hennessey Iain, Edgar David, Kenny Simon E., Early Cholecystectomy in Children with Gallstone Pancreatitis Reduces Readmissions, Journal of Pediatric Surgery (2015), doi: 10.1016/j.jpedsurg.2015.04.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT EARLY CHOLECYSTECTOMY IN CHILDREN WITH GALLSTONE PANCREATITIS REDUCES READMISSIONS
T
Authors: David J Wilkinson1,2, Nisarg Mehta3, Iain Hennessey1, David Edgar4, Simon E Kenny1,2
RI P
Institutions:
SC
1. Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
Liverpool, Eaton Road, Liverpool, L12 2AP, UK
NU
2. Reproductive and Developmental Medicine, Institute of Child Health, University of
MA
3. University of Liverpool Medical School, Cedar House, Ashton Street, Liverpool L69 3GE,
ED
UK
CE
Street, Liverpool L69 3GE, UK
PT
4. Cellular and Molecular Physiology, University of Liverpool, Sherrington Building, Ashton
Corresponding author:
AC
Mr Simon E Kenny
Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK Phone: 0151 2525434 Fax: 01512525677 Email: [email protected]
ACCEPTED MANUSCRIPT Abstract Background: Multiple guidelines exist in adult practice regarding the timing of
T
cholecystectomy for gallstone pancreatitis. Current evidence to support their
RI P
application to paediatric practice is minimal. This study sought to determine the effect
SC
of timing of cholecystectomy for gallstone pancreatitis in children on the risk of
NU
readmission
Method: All patients under 19 years of age presenting to an acute NHS trust in
MA
England with a diagnosis of gallstone pancreatitis between 1 January 1999 and 31 st
ED
December 2009 were included. Patient level data were extracted from the English
PT
Hospital Episode Statistic Database. ICD10, OPCS4.6 and hospital administrative
CE
data were used to determine: diagnosis, age, associated comorbidities and subsequent procedures performed.
AC
Results: 670 cases of gallstone related pancreatitis were recorded in under 19 year olds between 1999 and 2009 resulting in 3 deaths during this period. The majority (534/670) underwent a cholecystectomy which was performed less than two weeks from primary admission in 33% (174/534) of cases. Cholecystectomy within two weeks provides an actual risk reduction (ARR) of readmission of 57.5% (95%CI 50.1 to 64.4%, p0.05). Conclusions
ACCEPTED MANUSCRIPT Readmissions can be significantly reduced in this population by performing a cholecystectomy within two weeks with no apparent rise in surgical complications.
AC
CE
PT
ED
MA
NU
SC
RI P
T
Key Words: Gallstone pancreatitis; Pediatrics; Outcomes; Cholecystectomy
ACCEPTED MANUSCRIPT 1. Introduction Acute gallstone related pancreatitis (GRP) is rare in children; however, in the last decade there has
RI P
T
been a rise in incidence in children paralleling an increase in obesity.[1-4] Between 5.4-32.6% of cases of childhood pancreatitis are reportedly due to GRP.[2 3] Although GRP
SC
in children is usually mild, the incidence of recurrent episodes prior to cholecystectomy is high (25 60%),[5 6] and can be associated with both significant morbidity and mortality.[7 8] UK adult
NU
guidelines were published in 2005 recommending that cholecystectomy be performed in all patients
MA
no later than two-weeks after initial presentation and these guidelines have subsequently been validated by several studies.[9 -12] These guidelines were intended for adults, and the evidence as to
ED
the applicability of this guideline to children with GRP largely limited to small single institution retrospective case series.[13-15]. Of these the most significant study is that of Knott, et al, who
PT
reported a 36.8% recurrence rate of GRP associated with a delayed cholecystectomy, which could be
CE
prevented by operating within the index admission.
In their series of 22 children early
AC
cholecystectomy performed within the index admission was not associated with an increase in complications. [13]
The aim of this study was to determine the incidence and trends in admissions for gallstone pancreatitis in children at a population level between 1999 and 2009, and specifically to assess the applicability of the existing adult guideline for cholecystectomy within two weeks of presentation.
ACCEPTED MANUSCRIPT 2. Methods In order to counter the inherent problems caused by small sample size in the analysis of outcomes of
T
such surgical studies in children, we utilised the Hospital Episode Statistics (HES) database, a national
RI P
clinical data repository in England collated by the UK Department of Health, in which all patient episodes are individually recorded, detailing both administrative and clinical data. Each episode is
SC
linked via a unique patient identifier, allowing the patient to be tracked between institutions.
NU
For the purpose of this study we defined our paediatric population as all children under the age of 19
MA
years, this age limit was chosen firstly as there is very little published data on 16 to 18 year old children, with the majority of current studies limited to patients above this age. More importantly
ED
there is wide variety in the provision of medical care to the under 19 population, with a number of children in the 16-18year old bracket still receiving their definitive surgery in specialist paediatric
PT
centres. Treatment for GRP is provided by paediatricians, paediatric surgeons or surgeons with a
CE
predominant adult practice, with significant variation seen in the boundaries between paediatric and
AC
adult services in different geographical regions. Furthermore, there is often a lag period between the first episode of GRP and the subsequent cholecystectomy resulting in a number of episodes straddling the transition between paediatric and adult services. All cases of GRP in under 19 year olds presenting to secondary care providers between 1999 and 2009 were identified from the HES database, using the International Classification of Diseases, 10th revision (ICD10) diagnosis code for gallstone disease and pancreatitis (K800, K801, K802, K803, K805, K806, K807, K808, K809 & K85). Patients undergoing a cholecystectomy were identified using the Office of Population, Census & Surveys - Classification of Surgical Operations and Procedures, Fourth Revised Criteria (OPCS 4.6) codes for cholecystectomy (J181, J182 & J183). Population estimates for the under 16 and 18 year old populations were obtained from the UK National Statistics Authority.[16] Approval
ACCEPTED MANUSCRIPT for the use of HES data was obtained as part of the standard HES application process. Specific research ethic committee approval was not required as the study was limited to the analysis of a pre-
T
existing anonymised dataset.
RI P
The data were analysed to determine timing of cholecystectomy following the primary GRP related admission, subsequent readmissions either with recurrent episodes of pancreatitis or post-operative
SC
complications, and administrative and demographic data. Cases were then sub-grouped according to:
NU
the timing of cholecystectomy following initial presentation (2weeks) and age (0-16 years, 17-18 years). In order to identify post-operative complications, every subsequent admission for
MA
each case identified was individually analysed and complications recorded. For example, all cases of recurrent pancreatitis, retained stones and formation of pancreatic pseudocysts were identified
PT
cholecystectomy were excluded.
ED
based on both ICD and OPCS coding data. In addition, readmissions apparently unrelated to GRP and
CE
Statistical analyses were performed using GraphPad Prism Version 5 (GraphPad Software Inc.
AC
California, USA). Absolute risk reduction and Fisher’s exact test was used for independent categorical data and Mann-U Whitney for continuous non-parametric data. Correlation was assessed using Spearman’s Rank analysis. Statistical significance was set at p
