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At the children's hospital in Houston, Texas, 36 cholecystectomies were performed in the 20 years up to 1980. Between 1980 and 1996 there were 128 cholecystectomies of which 19 were laparoscopic (Darlene M Miltenburg and colleagues.Pediatrics2000;195:1250–3). Much of the increase may have been a consequence of ultrasound diagnosis but there appears to have been an increase particularly in children whose gallstones were not secondary to chronic haemolytic diseases. Of the 128 patients, only 29 had no underlying medical condition or risk factor. Fifty two had chronic haemolysis (31 had sickle cell disease and 16 hereditary spherocytosis). Other associated disorders or risk factors included gross obesity (8), cystic fibrosis (6), congenital heart disease (6), total parenteral nutrition as a preterm neonate (6), other long term use of total parenteral nutrition (4), family history of gallstones (3), and previous ileal resection (2). Twelve other patients had miscellaneous serious medical disorders. The average age was 10 years and seven were under 1 year. Sixty nine were girls. A quarter (32) of the cholecystectomies were performed as emergencies and complications developed after 16% of emergency and 6% of routine operations. Three children died, all after emergency surgery and all with congenital heart disease. Four of the six children with congenital heart disease underwent emergency surgery. The three who died were an 18 year old who had had an endocardial cushion defect repaired, a 17 year old with an artificial heart valve who had pulmonary vascular disease and had had surgery for truncus arteriosus, and a 10 month old who had had a heart transplant. (Gallstones develop in about 16% of children who have had a heart transplant.) Elective cholecystectomy is associated with less risk of complications than emergency cholecystectomy. Children with severe heart disease seem to be particularly at risk after emergency surgery.