Cholelithiasis and its associated comorbidities are no longer rare in the pediatric population. Once felt to be the sole purview of the adult general surgeon, pediatric surgeons are increasingly faced with patients who have biliary stone disease. This can be seen in all ages of pediatric patients from infants to adolescents 1. Biliary stones have even been reported in fetuses suggesting a potential genetic cause to their formation 2. Prevalence of cholelithiasis in children has reportedly increased from 1.9% to 4% and hospitalization rates of children with biliary stone disease, including choledocholithiasis and gallstone pancreatitis, have increased by 34% between 1997 and 2009 in some studies 2, 3, 4. However, more recent data suggest that this trend may be reversing, possibly due to a shift toward outpatient management. A recent analysis of the Kids’ Inpatient Database showed a 30% decline in cholelithiasis-associated hospitalization rates from 2006 to 2019 1. Interestingly, the proportion of hospitalizations at freestanding children’s hospitals increased significantly over this time from 18.2% to 35.1% confirming the need for pediatric providers to be comfortable with the management of gallstones 1

While the remainder of this issue will focus on the surgical management of cholelithiasis in the pediatric patient, it is important for pediatric surgeons to have a basic knowledge of the medical management of the disease. In some instances, the pediatric surgeon may be the most experienced provider available to manage the patient with biliary stone disease either due to a lack of pediatric gastroenterologists or due to a lack of comfort with managing these patients. This lack of comfort may arise when patients present with complicating features such as ascending cholangitis or gallstone pancreatitis. A main factor in the decision tree for the management of any patient with biliary stone disease is whether the stones are causing symptoms. With the increase in abdominal imaging for the workup of children with abdominal pain, pediatric patients may be diagnosed with an incidental finding of gallstones. It is important to determine if these gallstones are the etiology of the patient’s symptoms, especially prior to proceeding with a surgical approach. Even when they are symptomatic, an operative approach may not be the best initial step in the management of these patients. Non-operative management has focused on strategies to prevent the formation of new stones as well as attempts to reduce the stone burden through the dissolution of stones or the mechanical destruction of the stones through lithotripsy.

The etiology of gallstones in the pediatric patient is multifactorial. These reasons vary from children who require prolonged parenteral nutrition, sepsis, congenital heart disease, certain medications such as diuretics and cephalosporins, hemolytic disease, transplant patients, as well as obesity 5, 6, 7. Many of these risk factors have been known for some time, however, it is perhaps the recent obesity epidemic in the pediatric population that is driving the increased need for pediatric surgeons to not only perform more cholecystectomies but to also be able to manage the complications of stone disease 3,8,9. The underlying etiology is important to elucidate as this does impact the initial management of patients. Asymptomatic patients with underlying cholesterol stones may be managed non-operatively while patients with underlying hemolytic disorders may benefit from an earlier surgical approach even when asymptomatic, especially when they might require other surgical procedures such as splenectomy. One study showed that 71% of asymptomatic gallstones in patients with hereditary spherocytosis either remained stable in size or grew when observed, while only a minority resolved spontaneously. Early surgical management in these patients was associated with a lower risk of adverse effects 10. A similar study in children with sickle cell disease showed benefit when elective cholecystectomy was performed in asymptomatic patients rather than waiting until the patient became symptomatic or required urgent or emergent surgical intervention 11. These considerations are important to understand when determining the best management strategy especially in an asymptomatic patient.