Negative workup? Laparoscopic cholecystectomy Still alleviates symptoms.

BACKGROUND: Studies have shown that patients with abdominal pain and biliary dyskinesia (low ejection fraction <35 â€‹%) have significant improvement of symptoms following laparoscopic cholecystectomy, but there is lack of evidence that demonstrates whether patients with biliary symptoms and a normal ejection fraction (>35 â€‹%) will have similar results. METHODS: Retrospective, single center study of patients with biliary pain and negative workup, including HIDA with EF>35 â€‹%, who were treated with laparoscopic cholecystectomy from 2017 to 2022. RESULTS: There were 117 total patients. The mean age was 45.49 â€‹± â€‹15.5 years and 101 (86 â€‹%) were female. 101 (86 â€‹%) of patients underwent a right upper quadrant ultrasound, 91 had normal findings, 9 difficult to visualize anatomy and 1 had adenomyomatosis. All patients had a normal HIDA scan and ejection fraction 104 (89 â€‹%) of patients followed up in clinic within 30 days of surgical intervention. 87 (84 â€‹%) reported resolution of pre-operative symptomatology after surgical intervention. There was no statistically significant correlation between pain with CCK administration during HIDA (p â€‹= â€‹0.803) scan or ejection fraction (p â€‹= â€‹0.0977) with resolution of symptoms. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a beneficial intervention for patients with abdominal pain and normokinetic biliary disease. Offering surgical intervention early on can potentially save patients from exhaustive diagnostic investigations and possibly misdiagnosis.

Functional gallbladder disorder: Interim analysis of a prospective cohort study.

BACKGROUND: Functional gallbladder disorder (FGBD) remains a controversial indication for cholecystectomy. METHODS: A prospective cohort study enrolled patients strictly meeting Rome criteria for FGBD, and cholecystectomy was performed. They were assessed pre- and 3 and 6 months postoperatively with surveys of abdominal pain and quality of life (RAPID and SF-12 surveys, respectively). Interim analysis was performed. RESULTS: Although neither ejection fraction nor pain reproduction predicted success after cholecystectomy, the vast majority of enrolled patients had a successful outcome after undergoing cholecystectomy for FGBD: of a planned 100 patients, 46 were enrolled. Of 31 evaluable patients, 26 (83.9 â€‹%) reported RAPID improvement and 28 (93.3 â€‹%) SF12 improvement at 3- or 6-month follow-up. CONCLUSION: FGBD, strictly diagnosed, should perhaps no longer be a controversial indication for cholecystectomy, since its success rate for biliary pain in this study was similar to that for symptomatic cholelithiasis. Larger-scale studies or randomized trials may confirm these findings.

Defining Biliary Hyperkinesia and the Role of Cholecystectomy.

BACKGROUND: Functional gallbladder disorder is most commonly defined by biliary colic and low ejection fraction (EF) on cholescintigraphy. Biliary hyperkinesia is a controversial type of functional gallbladder disorder, and its definition and the role of cholecystectomy in treating functional gallbladder disorder remains unclear. STUDY DESIGN: We conducted a retrospective review of patients who underwent cholecystokinin-stimulated cholescintigraphy and cholecystectomy at 3 Mayo Clinic sites between 2007 and 2020. Eligible patients were 18 years or older, presented with symptoms of biliary disease, had an EF greater than 50%, underwent cholecystectomy, and had no evidence of acute cholecystitis or cholelithiasis on imaging. We used receiver operating characteristics curve analysis to identify the optimal cutoff value that predicted symptom resolution within 30 days of cholecystectomy. RESULTS: A total of 2,929 cholecystokinin-stimulated cholescintigraphy scans were performed during the study period; the average EF was 67.5% and the median EF was 77%. Analyzing those with EFs greater than or equal to 50% yielded 1,596 patients with 141 (8.8%) going on to have cholecystectomy. No significant differences were found in age, sex, BMI, final pathology between patients with and without pain resolution. Using a cutoff EF of 81% was significantly associated with pain resolution after cholecystectomy (78.2% for EF greater than or equal to 81% vs 60.0% for EF less than 81%, p = 0.03). Chronic cholecystitis was found in 61.7% of the patients on final pathology. CONCLUSIONS: We determined that an EF cutoff of 81% is a reasonable upper limit of normal gallbladder EF. Patients with biliary symptoms and an EF greater than 81% but no evidence of biliary disease on ultrasound or scintigraphy can be classified as having biliary hyperkinesia. Based on our findings, we recommend cholecystectomy for this patient population.

Use of endoscopic gallbladder stenting and biliary scintigraphy for diagnosis of gallbladder dyskinesia: a case report.

A 40-year-old woman visited our hospital with a several-year history of right hypochondriac pain and vomiting after eating. She had been treated for functional dyspepsia, with no improvement in her symptoms. No gallstones were detected on imaging tests, but papillary insufficiency or dyskinesia of the gallbladder was suspected and biliary scintigraphy was performed. Biliary scintigraphy showed delayed excretion of radionuclides from the gallbladder and bile ducts into the duodenum. We initially suspected papillary dysfunction and performed endoscopic sphincterotomy, but there was no improvement in her symptoms. Biliary scintigraphy also showed delayed excretion of radionuclides, especially stagnation of radionuclides in the gallbladder. We suspected gallbladder dyskinesia and performed endoscopic gallbladder stenting, after which her symptoms disappeared and biliary scintigraphy showed improved excretion of radionuclides into the duodenum. Endoscopic gallbladder stenting may be useful for the diagnosis of gallbladder dyskinesia and for determining the efficacy of cholecystectomy.

Gallbladder Dyskinesia.

Gallbladder dyskinesia is a functional disorder of the gastrointestinal tract, which can result in debilitating episodes of abdominal pain and associated symptoms. Key diagnostic criteria include a diminished gallbladder ejection fraction on scintigraphy and absence of other causes for the symptoms. Pathologic findings and follow-up suggest a distinct mechanistic basis for this condition. Unfortunately, the complexities of diagnosis and treatment combined with patient and provider preferences will likely continue to preclude randomized controlled studies to provide a clearer evidence-based management for this disorder. Patients meeting the clinical and diagnostic criteria for gallbladder dyskinesia should be referred for cholecystectomy, and most of these patients will have relief of their symptoms. A comprehensive preoperative discussion on expected outcomes needs to take place.

Pediatric Normokinetic Biliary Dyskinesia: Pain with Cholecystokinin on Hepatobiliary Iminodiacetic Acid Scan Predictive of Symptom Resolution After Cholecystectomy.

Introduction: Biliary dyskinesia is typically defined as a gallbladder ejection fraction (EF) <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA) testing. Cholecystectomy often leads to resolution of associated biliary colic symptoms. Alternatively, there is a subset of symptomatic patients with normal gallbladder EF on CCK-HIDA. It has been proposed that pain with CCK injection is more predictive of symptom resolution after cholecystectomy than low gallbladder EF. We reviewed our experience with pediatric patients with positive CCK provocation testing and a normal gallbladder EF in the absence of gallstones. Materials and Methods: We retrospectively reviewed the records of all pediatric patients with normal hepatobiliary iminodiacetic acid EFs (35%-80%) and pain with CCK injection at a tertiary care center between 2016 and 2020. Age, gender, body mass index (BMI), CCK-HIDA results, and pathology analysis were noted. Short- and long-term resolution of symptoms was determined by patient self-reporting at a mean of 3 weeks and 46 months, respectively. Results: Seventeen patients met inclusion criteria. Average age was 15.1 years (range, 12-17 years) with median BMI 24.9 (± 4.9 kg/m2). Mean CCK-HIDA EF was 56.3% (± 11.4%). In total, 62.5% of patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology analysis. Of patients available for short-term and long-term postoperative follow-up, 80% and 83% reported complete or near complete resolution of symptoms, respectively. Conclusions: Normokinetic biliary dyskinesia is poorly understood but appears to be associated with chronic inflammation and cured by surgical intervention. Laparoscopic cholecystectomy results in resolution of symptoms for a majority of patients and should be considered in those with pain with CCK injection despite normal imaging studies. Clinical Trial Registration Number: 1657640-2.

Outcomes After Laparoscopic Cholecystectomy in Hyperkinetic Biliary Dyskinesia.

BACKGROUND: Biliary dyskinesia (BD) is a poorly understood functional gallbladder disorder. Diagnosis is made with abdominal pain and an intact gallbladder without signs of anatomical obstruction on imaging or pathology. Our aim was to assess whether laparoscopic cholecystectomy (LC) resolves hyperkinetic BD symptoms. METHODS: Records of patients ≥18 years of age, who underwent LC by four surgeons at a tertiary care center between 2012 and 2020, were retrospectively reviewed. Patients were excluded if they had a documented gallbladder ejection fraction (GBEF) <80% or had biliary stones or sludge on pathology or imaging. Demographic information, HIDA results, preoperative testing, operative details, gallbladder pathology, and symptom status at follow-up were collected from electronic medical records. Improvement in BD symptoms was assessed using McNemar's test. Risk differences with standard errors were employed to estimate percent reduction in symptoms. RESULTS: Ninety-eight patients met inclusion criteria. Of those who presented for follow-up (n = 91), 92.3% (n = 84) reported partial or complete resolution of symptoms. Preoperative symptoms, including back pain (16.7%, 95% CI: [7.9%, 25.5%]; P < .0001), epigastric pain (31.1% [21.3%, 41.3%]; P < .0001), nausea (56.7% [45.0%, 65.8%]; P < .0001), RUQ pain (57.8% [46.1%, 66.9%]; P < .0001), and vomiting (27.8% [18.4%, 37.7%]; P < .0001) showed significant improvement after LC. Chronic cholecystitis and/or cholesterolosis were present on pathology in 79.8% of gallbladders. DISCUSSION: Our study currently represents the largest cohort of patients with hyperkinetic BD. Laparoscopic cholecystectomy appears to result in resolution of symptoms for this clinical entity.

Sex Disparities in the Presentation of Gallbladder Disease.

INTRODUCTION: Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients. METHODS: All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted. RESULTS: Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient. CONCLUSION: These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.

A pediatric surgeon's dilemma: does cholecystectomy improve symptoms of biliary dyskinesia?

BACKGROUND: Biliary dyskinesia (BD) is a well-established gallbladder pathology in adult patients and rates of cholecystectomy for BD continue to rise in the United States. Many pediatric patients with vague abdominal pain of variable duration are evaluated for biliary dyskinesia. It remains unknown which cohort of pediatric patients diagnosed with BD are most likely to have sustained improvement in symptoms following laparoscopic cholecystectomy. We aimed to determine whether cholecystectomy resulted in symptom relief and led to a reduction in the number of medical visits related to gastrointestinal (GI) symptoms after surgery. METHODS: We performed a multi-institution retrospective review of all children < 18 years of age who underwent laparoscopic cholecystectomy for BD between January 2013 and April 2018 in our hospital system. GI symptoms and clinical visits related to a GI complaint were assessed preoperatively. Patients were followed for 2 years after surgery. At 6 months and 2 years postoperatively, symptoms and the rate of medical visits related to a GI complaint were quantified and compared to the preoperative values. RESULTS: In total, 45 patients met our inclusion criteria. Of these, 82% of patients were female. The average age was 14 years old (± 2.6) and 56% of patients met the criteria for being overweight or obese. The mean gallbladder ejection fraction was 13% (± 10.8). All patients had abdominal pain, 82% (37/45) presented with nausea, and 51% (23/45) presented with post-prandial pain. Six months postoperatively, 58% of patients experienced resolution of their abdominal pain which decreased to 38% of patients after 2 years. Similarly, 59% had resolution of their nausea at 6 months compared to 43% at 2 years, and 100% had resolution of their post-prandial pain at 6 months compared to 91% at 2 years. The total number of clinical visits related to a GI complaint decreased from 2.6 (± 2.4) preoperatively to 1.0 (± 1.3) within 6 months postoperatively. When followed to 2 years postoperatively, the 6-month rate of clinical visits related to a GI complaint decreased from a mean of 2.6 preoperatively to 0.71 following surgery. CONCLUSIONS: Following cholecystectomy, we observed a high percentage of durable symptom resolution in those patients with BD who presented with post-prandial pain. Patients with non-food-related abdominal pain, with or without nausea and vomiting, had a lower rate of symptom resolution after surgery and the rate declined with time. For patients without post-prandial pain, evaluation and treatment of alternative sources of pain should be considered prior to surgery. Regardless of their presenting symptoms, patients who underwent surgery for BD had fewer clinical GI-related visits after surgery. However, no specific gallbladder ejection fraction or symptom alone was predictive of a lower rate of clinical visits postoperatively.

Biliary hyperkinesia: an indication for cholecystectomy?

BACKGROUND: The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. METHODS: Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17 years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2 weeks and 10-16 months after surgeries. RESULTS: Over 7 years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. CONCLUSIONS: In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Biliary Dyskinesia: Current Perspectives and Future Directions.

Biliary dyskinesia (BD) is a disorder characterized by functional biliary pain, the absence of gallstones on ultrasound, and the finding of a reduced gallbladder ejection fraction on a cholecystokinin-cholescintigraphic scan. Cholecystectomy remains a commonly applied treatment for BD, despite a lack of high-quality evidence supporting the practice. The following article provides an overview of the current diagnostic strategies, treatment outcomes with both surgical and nonsurgical treatment, emerging considerations related to special populations, and suggestions for addressing the identified knowledge gaps, moving forward in an effort to develop stronger, more evidence-based practice guidelines for treating this poorly understood and poorly studied condition.

Biliary Dyskinesia: Fact or fiction?

Nearly 20,000 pediatric patients undergo cholecystectomy annually, and abnormal gallbladder emptying ("biliary dyskinesia") has replaced cholelithiasis as the leading indication for this operation in the USA. Nonetheless, patients with abnormal gallbladder emptying nuclear medicine scans do not uniformly benefit from cholecystectomy. This article reviews the available data on presentation, workup and treatment of patients with abnormally low and high rates of gallbladder emptying.

What is the role of the cholecystokinin stimulated HIDA scan in evaluating abdominal pain in children?

PURPOSE: Cholecystokinin stimulated HIDA (CCK-HIDA) has been used to identify patients with biliary dyskinesia and select patients likely to benefit from cholecystectomy. The appropriate use of this study in children remains controversial and this study aims to better understand the utility of this test. METHODS: Children who underwent a CCK-HIDA for evaluation of abdominal pain over a 15-year period were included, after excluding infants and patient's s/p liver transplant. Relevant clinical and outcomes data were abstracted and analyzed. RESULTS: 124 patients met inclusion criteria. Mean age was 14.5 ± 2.6 years, Mean BMI was 27.9 ± 9.9 and 96 (77.4%) presented with right upper quadrant or epigastric pain. The mean ejection fraction (EF) was 58.5 ± 31.8%, with 37 (29.8%) < 35% EF. Using receiver operating curve analysis no specific EF threshold value predictive of resolution of symptoms was identified (AUC 0.510; p = 0.94). Using EF <35% and >35% and <20% and >20%, no association was noted with partial/complete resolution of symptoms. On multivariate regression analysis neither EF nor pain reproduction with CCK administration were independently associated with resolution of symptoms. CONCLUSIONS: These data suggest that the CCK-HIDA scan is a poor predictor of benefit from cholecystectomy. Prospective large studies would help in identifying better criterion for patient selection, especially with the trend of increasing surgery for functional gallbladder disorders. TYPE OF STUDY: Case cohort. LEVEL OF EVIDENCE: IV.

Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review.

BACKGROUND: Patients with typical biliary pain, no gallstones on ultrasound and low gallbladder ejection fraction (GBEF) on cholescintigraphy (gallbladder dyskinesia) may be considered for a laparoscopic cholecystectomy. However, some studies have suggested that symptoms alone are an adequate indication for laparoscopic cholecystectomy. The aim was to determine the role of cholescintigraphy in predicting outcomes of cholecystectomy in patients with typical and atypical biliary symptoms and normal biliary ultrasound. METHODS: Meta-analysis using Preferred Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines of published literature using several electronic databases. RESULTS: Twenty-four articles were selected with a total of 1710 patients. The majority (n = 1633, 94.4%) of patients had typical biliary symptoms. A total of 1047 patients with typical symptoms and a reduced GBEF had a cholecystectomy with 852 (81.4%) having complete resolution of symptoms. A total of 148 with typical symptoms and normal GBEF had a cholecystectomy with 103 (69.5%) having complete resolution, which was significantly less than those with a reduced GBEF (odds ratio 1.65, confidence interval 1.08-2.05, P = 0.01). Forty-five patients with atypical symptoms and a reduced GBEF had a cholecystectomy with 31 (68.9%) having complete resolution of symptoms, which is significantly lower than those with typical symptoms (odds ratio 1.97, confidence interval 0.95-3.90, P = 0.05). CONCLUSION: Cholescintigraphy improved the predication of outcome of cholecystectomy in biliary dyskinesia by 10%. However, the presence of typical symptoms does predict an effective response in 70% of patients. Atypical symptoms predict a poorer response.

Self-reported Outcomes After Cholecystectomy for Pediatric Hyperkinetic Biliary Dyskinesia.

BACKGROUND: Biliary dyskinesia (BD) is a common indication for cholecystectomy in children. Current literature demonstrates an improvement in symptoms after cholecystectomy in most pediatric patients with an EF <35%; however, data supporting the efficacy of cholecystectomy for hyperkinetic BD (EF >65%) is sparse. We sought to determine whether children with hyperkinetic BD (HBD) had resolution of their symptoms after laparoscopic cholecystectomy at our institution. MATERIALS AND METHODS: We conducted a retrospective chart review of children who had undergone laparoscopic cholecystectomy for HBD at our institution between September 2010 and July 2015. Patients completed a phone survey about symptom resolution, whether they were happy to have undergone cholecystectomy, overall satisfaction on a 1-10 scale, and additional workup for those with ongoing pain. Analysis was performed using STATA statistical software with a P-value < 0.05 as statistically significant. RESULTS: Thirteen patients met inclusion criteria. Median gallbladder ejection fraction was 93% [IQR: 90, 97]. Median postoperative follow-up was 59 d [IQR: 25, 151] at which time 50% reported resolution of symptoms. Eight patients participated in the survey at a median follow-up of 45 mo [IQR: 40, 66]. Fifty percent reported ongoing abdominal pain. Frequency of pain varied among patients with pain, occurring from <1 time per week to a few times per day. Five patients (63%), including one patient with ongoing pain, were happy that their gallbladder had been removed and overall satisfaction rating was 5 on a scale of 1-10. CONCLUSIONS: Only half of children with HBD were asymptomatic at long-term follow-up. Cholecystectomy for HBD may or may not improve symptoms.

Surgical outcome in patients with biliary colic and atypical workup findings.

BACKGROUND: Surgical response of patients with symptomatic biliary colic but atypical findings of gallbladder polyps, hyper-dynamic gallbladder and otherwise negative biliary workup are underrepresented in the literature from community practice. METHODS: A clinical outcome study with a retrospective design compared the short term and long term symptomatic improvement reported by patients with pre-operatively diagnosed biliary dyskinesia to all other biliary colic patients with atypical pre-operative diagnoses. All patients underwent surgery at Meridian Surgery Center from the years 2010-2017.600 patients were reviewed for biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative workup. RESULTS: Short term and long term results were compiled from a total 182 patients. Short term response rates were assessed from 74 biliary dyskinesia, 40 hyperdynamic, 23 gallbladder polyps, and 45 negative workup patients. Long term responses were received from 19 biliary dyskinesia patients, 11 hyperdynamic patients, 9 polyp patients, and 7 negative workup patients. Long term improvement among biliary dyskinesia patients was 84%, and 83% among patients with atypical findings, representing a long term drop in symptoms. There is no significant difference between symptom recovery of patients with biliary dyskinesia and those with another atypical diagnosis: hyper-dynamic (82%), polyps (89%), negative workup (57%). CONCLUSION: These results allow us to conclude that there is a comparable biliary colic improvement between biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative workup patients after cholecystectomy in both short term and long term follow up.

Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Cholecystectomy for Biliary Hyperkinesia.

Patients with classic biliary colic symptoms and documented gallbladder ejection fractions on the higher end of the spectrum on hepatobiliary iminoacetic acid scans with cholecystokinin stimulation are presently understudied and the benefits of cholecystectomy are unclear. To determine whether patients with biliary-type pain and biliary hyperkinesia (defined as a gallbladder ejection fractions of 80% or greater) benefit from laparoscopic cholecystectomy, a retrospective chart review encompassing five community hospitals was performed. Patients 16 years and older with diagnosed biliary hyperkinesia who underwent laparoscopic cholecystectomy between January 1, 2010 and May 31, 2015 were included. Pathology reports were reviewed for histologic changes indicating cholecystitis. Resolution of biliary colic symptoms was reviewed one to three weeks after surgery in their postoperative follow-up documentation. Within our study cohort, we found 97 patients who underwent laparoscopic cholecystectomy for biliary hyperkinesia. Within this population, 84.5 per cent of patients undergoing laparoscopic cholecystectomy for biliary hyperkinesia had positive findings for gallbladder disease on final pathology. Of the 77 patients with data available from their first postoperative visit, 70 (90.9%) reported improvement or resolution of symptoms. Our findings suggest that symptomatic biliary hyperkinesia may be treated successfully with surgery.

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

BACKGROUND: Gallbladder dyskinesia (gallbladder spasm, biliary dyskinesia or chronic acalculous cholecystitis) is a poorly defined entity which presents as biliary-type pain without any identifiable organic pathology. Abnormal gallbladder ejection fraction (GBEF) is used by some to select those likely to benefit from cholecystectomy. The validity of this approach has been questioned. AIM: To systematically review the literature and summarise the evidence surrounding the practice of cholecystectomy based on GBEF for gallbladder dyskinesia. METHODS: We conducted a systematic search of PubMed/MEDLINE and SCOPUS from 1980 to 2016 to identify the relevant literature. RESULTS: Twenty-nine studies including 2891 patients were included in the final analysis. In comparing cholecystectomy with medical management, patients with a normal GBEF did not benefit from cholecystectomy; whereas those with low GBEF had a higher chance (RR, relative risk = 2.37) of symptomatic improvement following surgery. When those classified as "low" and "normal" GBEF were compared in terms of outcome following cholecystectomy, the rate of improvement following surgery was similar in the two groups (RR 1.09) which suggests a placebo effect of surgery. CONCLUSIONS: While a low GBEF may provide some guidance in identifying those with gallbladder dyskinesia who may benefit from cholecystectomy, the available data are inconsistent and based on studies of poor quality which are often subject to bias and the impact of confounding factors. For these reasons, we conclude that the role of scintigraphy and cholecystectomy in the definition and management of this disorder remain unclear pending definitive study.