In the largest study to date on the impact of cholecystectomy on readmission rates in children with BAP or choledocholithiasis, we found that cholecystectomy performance was associated with lower prevalence of readmission and lower length of stay during index admission. In these children, the rationale for cholecystectomy during the index admission is to avoid the potential complications of delayed surgery, such as recurrent episodes of acute cholecystitis, pancreatitis, and cholangitis, which may require emergency surgery, longer hospital stays, and increased healthcare costs. This approach has been recommended in recent guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), but based on very limited data from smaller cohorts; this study provides data from a national cohort to support the recommendation [10,11,12,13, 16, 17].

Despite current recommendations, pediatric index cholecystectomy was only performed in 59% of admissions for biliary acute pancreatitis and choledocholithiasis. Interestingly, this trend is mirrored in multiple analogous retrospective studies in the adult literature, even after the foundational randomized controlled PONCHO trial, which showed that compared with delayed cholecystectomy, index admission cholecystectomy reduced rate of recurrent gallstone-related complications in patients with mild BAP [6,7,8, 18]. These findings were momentous in adult literature and emphasized the needless hospital readmission and healthcare utilization brought on by delayed cholecystectomy.

The adoption of index cholecystectomy likely varies among pediatric centers across the country. Several factors may influence the decision to perform index cholecystectomy in pediatric patients, including the severity of presentation and the availability of resources. However, given the burden of disease and healthcare utilization, the adoption of cholecystectomy on index admission in choledocholithiasis and mild BAP appears key to outcomes in children with gallstone disease. Though there is research reporting no difference in technical complexity between early and delayed cholecystectomy, there may remain concerns about performing surgery shortly after pancreatitis episode [19]. Additionally, though guidelines and recommendations represent ideal policies, their implementation may not always be pragmatic, particularly at hospitals with limited resources or those with economic constraints [20].

Although ERCP was performed in less than 40% of children with choledocholithiasis, it conferred a staggering 79% reduction in 30-day readmission when performed. This may reflect the limited number of pediatric advanced endoscopists and warrants further independent study to better characterize need and utilization of pediatric ERCP [21].

Our results showed that longer length of stay was associated with greater likelihood of readmission, though extreme severity of disease—as defined by APR-DRG—conveyed a lower likelihood of readmission after adjusting for significant factors. This was likely caused by the low number of patients with extreme severity of disease who had length of stay greater than 7 days allowing for greater skew of data.

We acknowledge several limitations to this study. This is a retrospective study, which can demonstrate associations but not establish causality. The use of a national database that is reliant on ICD-10 coding can include coding errors or omissions in the database. Additionally, the NRD does not have information on vitals, lab values, or imaging and thus disease severity to allow for granular analysis of children’s clinical conditions. Information on patients who received cholecystectomy as an outpatient after index admission was not obtainable, although we suspect this is rare. We also could not evaluate social risk factors for readmission. Nevertheless, this represents the largest study cohort in the pediatric population and suggests that cholecystectomy on index admission should be standard of practice for pediatric BAP and choledocholithiasis.

In conclusion, in children admitted for BAP or choledocholithiasis, hospital discharge before cholecystectomy was associated with a significantly increased odds of readmission. Further studies are needed to determine the barriers to cholecystectomy and differential availability based on patient and hospital-level factors. In addition, the development of standardized protocols could help to increase the adoption of pediatric index cholecystectomy and improve outcomes for children.