Journal of Pediatric Surgery 58 (2023) 564–567

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg.org

Post-cholecystectomy syndrome in pediatric patients: Occurrence and

spectrum of symptoms
Martin Treider a,∗, Susanne Ohnesorge a,1, Kristin Bjørnland a,b
a
Oslo University Hospital, Mailbox 4950, Nydalen, Oslo 0424, Norway
b
University of Oslo, Oslo, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Background: Post-cholecystectomy syndrome (PCS) refers to persistent or new abdominal symptoms af-
Received 16 March 2022 ter cholecystectomy. As there are very few reports on PCS in pediatric patients, we aimed to examine
Revised 5 July 2022
whether it was a frequent finding and which symptoms the affected children experienced.
Accepted 10 July 2022
Method: This is a retrospective cross sectional study of pediatric patients, who underwent cholecys-
tectomy during 2003–2019 at Oslo University Hospital. The PedsQLTM gastrointestinal symptoms scale
Keywords: questionnaire and a self-designed questionnaire exploring satisfaction after surgery and current medical
Post-cholecystectomy syndrome conditions were mailed to all eligible patients. Patient/parental consent and approval from the local data
Cholecystectomy protection officer (19/09054) were obtained.
Patient satisfaction
Results: Questionnaires were sent to 82 patients of whom 44 (54%) answered. There were no signifi-
Gallstone disease
cant demographic differences between the responders and the non responders. We identified 16 (36.7%)
patients to have PCS. The most common symptoms were diarrhea (25%), bloating (16%), and heart-
burn/reflux (16%). Overweight was more common in patients with PCS (31%) than in patients without
PCS (4%) (p = 0.014). Altogether 34/44 (77.3%) patients were satisfied with the result of the cholecystec-
tomy; 92,6% of patients without PCS and 56.6% of those with PCS (p = 0.012).
Conclusion: PCS is not uncommon in pediatric patients, and they report a wide range of gastrointesti-
nal symptoms. We identified overweight as a potential risk factor for developing PCS. Nonetheless, most
patients got total relief of abdominal pain and were satisfied with outcome after cholecystectomy.
Level of evidence: Level 3
© 2022 The Author(s). Published by Elsevier Inc.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

1. Introduction causes of non biliary symptoms [6]. Increased bile flow into the
upper gastrointestinal tract may lead to duodeno-gastric biliary
The prevalence of gallstones in children is reported to vary reflux, which may play a significant role in the pathogenesis of
from 0.1 to 1.9% [1–3]. There are several risk factors for develop- symptoms like dyspepsia, gastric/ duodenal ulcer, and nausea [7].
ing gallstones in childhood. These include hemolytic disease, long- Biliary etiologies of PCS include bile salt-induced diarrhea, retained
term parenteral nutrition, genetic disorders, trauma, sepsis, antibi- calculi, bile leak, biliary strictures, long remnant cystic duct, and
otics, and obesity [4]. Cholecystectomy is the standard treatment dyskinesia of the sphincter Oddi [8].
for symptomatic gallstone disease in both adults and children. Un- In adults, PCS occurs in 5–47% and is significantly more com-
fortunately, not all patients experience total relief of symptoms af- mon in women than in men [5,9–11]. It is only one previous pub-
ter cholecystectomy, and some even develop new gastrointestinal lished study on PCS in the pediatric population. This study, pub-
symptoms postoperatively. Post-cholecystectomy syndrome (PCS) is lished in Spanish, including 33 patients found that 48% experi-
a term used to describe the persistence or occurrence of abdominal enced PCS [12]. We performed this study to expand current knowl-
symptoms after cholecystectomy [5]. edge about PCS in children, and our primary objective was to ex-
PCS symptoms are often divided into biliary and non biliary plore the frequency of PCS in these patients. Our secondary aims
symptoms. Undiagnosed extra-biliary diseases, such as irritable were to investigate the spectrum of PCS symptoms and patient/
bowel syndrome or functional dyspepsia are the most common parent satisfaction after cholecystectomy.

2. Patients and methods

∗
Corresponding author.
E-mail address: [email protected] (M. Treider). This is a retrospective cross sectional study of patients <18
1
Shared first authorship. years who underwent cholecystectomy during 2003–2019 at Oslo

https://doi.org/10.1016/j.jpedsurg.2022.07.011
0022-3468/© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
 M. Treider, S. Ohnesorge and K. Bjørnland / Journal of Pediatric Surgery 58 (2023) 564–567 565

University Hospital, which serves as a local, regional, and tertiary rent cholecystitis, choledochal stones, biliary pancreatitis, and/or
referral center in pediatric surgery. Patients who underwent chole- cholangitis). The indication for cholecystectomy was pain in 25
cystectomy as a part of liver resection, resection of choledochal (61%), common bile duct stones in seven (17%), and cholecystitis
cysts, or Kasai portoenterostomy were excluded. Clinical details in three (7%). Three patients did not have symptoms of gallstone
such as age at surgery, gender, comorbidities, body mass index, in- disease, but had the gallbladder removed concomitantly with (7%)
dication for cholecystectomy, surgical method (open/ laparoscopic other procedures, and none were operated for biliary dyskinesia
operation), and postoperative complications were recorded retro- alone. Fifteen (37%) patients had no other disease, ten (25%) had
spectively from medical records. Postoperative complications were hemolytic disease (hereditary spherocytosis (9 patients), hereditary
graded according to the Clavien-Dindo classification of complica- hemolytic anemia (1 patient)), four (9%) had gastrointestinal dys-
tions [13]. A more detailed description of the majority of the pa- motility disorders, four (9%) had neurological disorders, four (9%)
tients’ demographics and perioperative results has been described had a syndrome, and 15 (34%) had a variety of other disorders. La-
previously [14]. paroscopic cholecystectomy was performed in 40 (86%) patients,
The PedsQLTM gastrointestinal symptoms scale (GSS) question- 34 (78%) underwent elective surgery, and seven (15%) had a con-
naire and a self-designed questionnaire were mailed to the pa- comitant splenectomy. Seven (15%) patients experienced postoper-
tients and their parents. The PedsQLTM GSS questionnaire includes ative complications. Two (5%) patients experienced Clavien Dindo
a total of 58 items divided into 10 different domains: Stomach 3b complications; one common bile duct injury and one postop-
Pain (6 items), stomach discomfort when eating (5 items), trou- erative bleeding. The median time from operation to follow-up
ble swallowing (3 items), food and drink limits (6 items), heart- was five (0.5–16) years, and the mean age at follow-up was 14.9
burn and reflux (4 items), nausea and vomiting (4 items), gas and (SD=6.1) years. There were no demographic differences between
bloating (7 items), constipation (14 items), blood in stool (2 items), the patients who returned the questionnaires and those who did
and diarrhea (7 items). Answers are graded as 0=never a prob- not (Table 1).
lem, 1=almost never a problem, 2=sometimes a problem, 3=often Overall gastrointestinal quality of life was good (Table 2). Six-
a problem, 4=almost always a problem. To generate the total score, teen (37%) patients had abdominal symptoms fulfilling the defini-
answers are transformed reversely from a 0–4 scale to a 0–100 tion of PCS. These patients presented a variety of symptoms; diar-
scale, where 0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0. A rhea (11 patients), gas and bloating (7 patients) heartburn/reflux (7
high score indicates high gastrointestinal quality of life and few patients), stomach pain (5 patients), stomach discomfort when eat-
gastrointestinal symptoms. Scores are presented as the mean score ing (5 patients), nausea and vomiting (4 patients), food and drink
of the items within each domain and the mean total score for all intolerance (4 patients), constipation (3 patients), trouble swal-
items. If > 50% of items in one scale were missing, the scale score lowing (3 patients), and blood in stool (1 patient). The individ-
was not computed [15]. The non validated self-designed question- ual patients with PCS reported from one to six different abdom-
naire included questions on satisfaction with the cholecystectomy inal symptoms (1 symptom: 6 patients, 2 symptoms: 3 patients,
(yes/no/do not know), current medications, any abdominal surgery 3 symptoms: 2 patients, 4 symptoms: 3 patients, 6 symptoms: 2
after cholecystectomy, and any health contacts related to abdomi- patients).
nal pain after cholecystectomy. In patients < 12 years parents were The majority (80%) were satisfied with the result of the chole-
instructed to answer the questionnaire, patients 12–17 were in- cystectomy. Four (10%) were not satisfied, and four (10%) patients
structed to answer together with their parents and patients >18 were unsure. Two (4.5%) patients had undergone additional gas-
years were instructed to answer independently. trointestinal surgery after the cholecystectomy (liver resection and
We defined the patients to have an abdominal symptom if they appendectomy), and fifteen (34%) patients had been examined by
had a PedsQLTM GSS score lower than two standard deviations a doctor because of abdominal symptoms since the cholecystec-
from the mean score in a healthy control group [16,17] for one or tomy. Among patients with PCS, significantly more patients were
more domains. The patient‘s body mass index was adjusted for age overweight (Table 3). Fewer patients with PCS were satisfied with
and gender, and a body mass index >25 was categorized as being the postoperative result than those without PCS (Table 3). The fre-
overweight. quency of health contacts because of abdominal pain was also
Data were registered in EpiData Manager (version 4.6.0.2), and higher among patients with PCS (Table 3).
the statistical analysis was performed by use of SPSS statistics 28
(IBM corp. Armonk, NY). Numerical variables are presented as me- 4. Discussion
dian and range for not normally distributed data and as the mean
and standard deviation (SD) for normally distributed data. Chi- The main finding in this study is that PCS defined as new or
Square test was applied for comparison of all categorical variables. persisting abdominal symptoms after cholecystectomy is not un-
Continuous variables were analyzed with parametric test (Student common in pediatric patients as around one-third of the patients
T-Test) and non parametric test (Mann-Whitney-U test) used as ap- reported abdominal symptoms after the cholecystectomy. Only one
propriate. All age groups were analyzed together because of the previous study published in Spanish including 33 patients has ex-
low sample size. Patient/parental consent and approval from the amined how often PCS occurs in children [12]. The Spanish study
local data protection officer (19/09054) were obtained. found a similar rate of PCS as we did. The prevalence of PCS in
the present study is within the same range as reported in adults,
3. Results although at the higher end [5,9–11]. The small study populations
in both pediatric studies make it difficult to make any firm con-
We identified 86 eligible patients. Four patients were deceased clusion about the prevalence of PCS in children. That many of the
at follow-up. They had serious underlying neurological or syn- children had comorbidities has most likely contributed to the rel-
dromic conditions and died mean four years after surgery of causes atively high rate of PCS. Moreover, how abdominal symptoms are
unrelated to the cholecystectomy. Thus, questionnaires were sent defined and recorded may also affect how often PCS is reported.
to 82 patients of which 44 (54%) returned the questionnaires. All Diarrhea, bloating, and reflux/ heartburn were the most com-
patients returning questionnaires were included. Twenty-two (50%) mon symptoms after cholecystectomy. This is in line with what
were girls, and mean age at surgery was 8.6 (SD=3.9) years. All pa- is reported in adults [10,11]. Both diarrhea and bloating may be
tients had gallstones demonstrated on ultrasound preoperatively, a consequence of loss of the gallbladder’s reservoir function and
and 18 (42%) had complicated gallstone disease (previous or cur- may therefore be caused by the cholecystectomy. Reflux and dys-
566 M. Treider, S. Ohnesorge and K. Bjørnland / Journal of Pediatric Surgery 58 (2023) 564–567

Table 1
Responders versus non responders. A comparison of demographic and clinical data in 81 responders and non responders of questionnaires sent after cholecystectomy.
Being overweight was defined as an age and gender-adjusted body mass index >25.

Responders (n = 44) Non responders (n = 37) p value

Age, mean (SD) 8.6 (3.9) 10.2 (4.6) 0.088

Gender, girls 22 (50%) 30 (71.4%) 0.074
Body mass index, median (min-max) 16.4 (13−32) 18.3 (11−37) 0.127
Comorbidity
No comorbidity 15 (34.1%) 15 (40.5%) 0.646
Hemolytic disease 10 (22.7%) 10 (27.0%) 0.796
Being overweight 6 (13.6%) 8 (21.6%) 0.230
Syndromic disease 4 (9.1%) 2 (5.4%) 0.685
Other 17 (38.6%) 13 (35.1%) 0.819
Complicated gallstone disease 17 (38.6%) 16 (43.2%) 0.820
Long-term parenteral nutrition 4 (9.1%) 3 (8.1%) 1.000
Years from cholecystectomy to being invited to 5 (0–16) 5 (0–16) 1.000
participate, median (min-max)

Table 2
Gastro PedsQLTM gastrointestinal symptom scale score in patients with and without post-cholecystectomy syndrome (PCS) in patients undergoing cholecys-
tectomy in a pediatric department during 2003–2019.

Domain Patients without PCS score (SD), n = 28 Patients with PCS score (SD), n = 16 All patients score (SD), n = 44

Total score 90.6 (7.4) 66.5 (12.8) 82.7 (14.1)

Stomach Pain 85.4 (13.8) 49.6 (17.8) 72.9 (22.9)

Stomach Discomfort When Eating 89.3 (11.7) 65.1 (20.1) 80.8 (18.9)
Food and Drink Limits 89.1 (13.8) 68.3 (29.8) 81.9 (22.8)
Trouble Swallowing 97.0 (6.5) 87.2 (18.6) 93.6 (12.8)
Heartburn and Reflux 88.6 (13.7) 67.4 (22.6) 80.8 (20.1)
Nausea and Vomiting 94.4 (10.3) 77.1 (21.0) 88.4 (16.8)
Gas and Bloating 78.8 (18.0) 38.8 (13.8) 64.4 (25.2)
Constipation 85.8 (13.6) 64.3 (17.6) 78.9 (17.4)
Blood in Poop 98.2 (5.6) 87.5 (13.9) 94.6 (10.4)
Diarrhea 94.3 (9.4) 66.8 (18.3) 84.9 (18.5)

Table 3
Patients with and without post-cholecystectomy syndrome. A comparison of demographic and clinical data in patients
with and without post-cholecystectomy syndrome (PCS) after cholecystectomy in a pediatric department. The patient’s
body mass index was adjusted for age and gender, and body mass index >25 was categorized as overweight.

With PCS, n = 16 Without PCS, n = 28 p value

Gender, girls 7 (43.8%) 13 (51.9) 0.607

No comorbidity 5 (31.3%) 10 (37%) 0.700
Age at operation, median years (min-max) 8 (2–13) 10 (0.2–17) 0.217
Overweight at operation 5 (31.3%) 1 (3.7%) 0.014
Elective surgery 12 (75.0%) 23 (85.2%) 0.666
Complicated gallstone disease 6 (37.5%) 11 (40.7%) 0.834
Age at follow-up (median, min-max) 14.5 (3–25) 13.75 (6–29) 0.659
Follow-up time, median years (min-max) 5.5 (0–16) 5 (0–16) 0.785
Being overweight at follow-up 7 (43.8%) 3 (11.1%) 0.010
Overall satisfied with the result after the cholecystectomy 9 (56.6%) 25 (92.6%) 0.012
Examined by a doctor for abdominal pain after discharge 13 (81.3%) 2 (7.4%) <0.001

peptic symptoms have been reported both before cholecystectomy The majority of the patients were satisfied with the result of
and to increase postoperatively in many adult patients [18–20]. the cholecystectomy. This is in line with findings from studies on
Thus, reflux/ heartburn may both be a consequence of cholecystec- patient satisfaction after cholecystectomy in adults [23,24]. As ex-
tomy and a persisting symptom. It is interesting that postoperative pected, patients with PCS were less satisfied with the postoperative
symptoms are similar in children and adults in spite of children result than patients without PCS. Nonetheless, more than half of
often having a different pathogenesis and preoperative symptoms the patients with PCS were satisfied with the postoperative result.
compared to adults [21]. We interpret this finding as PCS patients had an overall reduction
Abdominal pain was the most common indication for cholecys- in abdominal symptoms after cholecystectomy.
tectomy, and about 90% of the patients in this study had total relief More patients with PCS were overweight at the time of surgery
of their abdominal pain postoperatively. This is within the same and at follow-up compared to those without PCS. Similar results
range as reported in adults, where the rate of total recovery from have not been found in adults. We do not have any obvious ex-
abdominal pain varies between 60% and 100% [10,11,22]. As men- planation for this finding, and further research is needed. PCS is
tioned earlier, pediatric patients undergoing cholecystectomy often reported more frequently among adult women than men [5,9–11].
have comorbidities that may cause abdominal symptoms. There- In contrast, we did not demonstrate any gender difference. That
fore, it is positive that the cholecystectomy had such a good effect many of the patients in this study were prepubertal may be one
on abdominal pain in nine out of ten patients. This finding suggests explanation for the lack of gender difference in the frequency of
that cholecystectomy is a good treatment for gallstone-related pain PCS.
in pediatric patients.
 M. Treider, S. Ohnesorge and K. Bjørnland / Journal of Pediatric Surgery 58 (2023) 564–567 567

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