# Choledocholithiasis — GCMD Library living collection

Everything in the library about choledocholithiasis — built automatically from dossiers that name it.

Updated: n/a · 4 episodes · 42 cited statements

## Episodes
### Surgical Management
- [Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706) — video · 7:31 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706.md)

### Evidence & Research
- [Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558) — video · 1:04 · [machine version](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558.md)
- [Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122) — video · 0:59 · [machine version](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122.md)

### In-Depth Reviews
- [Choledocholithiasis with Drs. David Vitale & Lucas Neff](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884) — podcast · 15:27 · [machine version](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=0) Study Overview: Transcystic Laparoscopic CBD Exploration vs ERCP (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=0) Introduction and Risk Stratification (Ep 2)
- [2:38](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=158) Pediatric Predictors and Treatment Approaches (Ep 2)
- [5:17](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=317) Surgery-First Paradigm (Ep 2)
- [9:37](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=577) Technical Details of Laparoscopic CBD Exploration (Ep 2)
- [13:47](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=827) Learning Curve and Summary (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=0) Surgery-First Approach for Pediatric Choledocholithiasis (Ep 3)
- [0:01](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=1) Introduction and Course Context (Ep 4)
- [1:06](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=66) Case 1: Surgery-First vs ERCP-First Approach (Ep 4)
- [2:59](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=179) ERCP Complications and Stone Clearance Rates (Ep 4)
- [5:00](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=300) Technical Considerations and Equipment (Ep 4)
- [5:43](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=343) Case 2: Sickle Cell Patient and Flushing Risks (Ep 4)
- [6:45](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=405) Summary and Conclusions (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Choledocholithiasis is more common in older children, children with higher BMI, and patients of Hispanic ethnicity" — David Vitale (epidemiological) [Ep 2 · 1:03](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=63)
- "Risk factors for choledocholithiasis include metabolic diseases, hemolysis such as sickle cell, and congenital biliary anomalies like choledochal cysts" — David Vitale (clinical) [Ep 2 · 0:55](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=55)
- "According to ASGE guidelines, patients with high probability of common bile duct stones (common bile duct stones seen on ultrasound, ascending cholangitis, or quite high bilirubin) should go straight to ERCP" — David Vitale (guideline) [Ep 2 · 1:52](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=112)
- "Patients with intermediate risk (abnormal liver biochemical tests or dilated common bile ducts) can undergo endoscopic ultrasound, MRCP, laparoscopic cholangiogram, or intraoperative ultrasound" — Cecilia Gigena (guideline) [Ep 2 · 2:11](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=131)
- "In pediatric patients, direct bilirubin or conjugated bilirubin more than 2 was the most predictive factor for common bile duct stones" — David Vitale (clinical) [Ep 2 · 2:40](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=160)
- "Common bile duct diameter greater than 6 millimeters was most sensitive for predicting common bile duct stones in children, although without statistical significance" — Cecilia Gigena (clinical) [Ep 2 · 2:50](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=170)
- "The pediatric duct score (published in Journal of American College of Surgeons with 10 centers) found that ducts greater than 6 millimeters, common bile duct stones on ultrasound, or total bilirubin greater than 1.8 were the most predictive risk factors" — David Vitale (clinical) [Ep 2 · 3:03](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=183)
- "Pediatric literature with small sample size shows that doing same anesthesia laparoscopic cholecystectomy with ERCP in stone disease led to less anesthesia time and lower length of stay" — David Vitale (clinical) [Ep 2 · 3:41](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=221)
- "Retrospective data comparing ERCP versus laparoscopic common bile duct exploration is conflicted and the choice is probably institution and provider dependent based on expertise" — David Vitale (opinion) [Ep 2 · 4:03](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=243)
- "Randomized trials from 2013 show no significant difference in morbidity, mortality, retained stones, or failure rates between ERCP and laparoscopic common bile duct exploration" — Cecilia Gigena (clinical) [Ep 2 · 4:18](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=258)
- "Stones above the cystic duct pose a problem because they can float up during attempted laparoscopic removal, making the procedure more difficult" — David Vitale (clinical) [Ep 2 · 4:39](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=279)
- "Local expertise and availability is probably the most important factor in deciding between ERCP and laparoscopic common bile duct exploration" — David Vitale (opinion) [Ep 2 · 5:00](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=300)
- "Most free-standing children's hospitals do not have ERCP capabilities" — Cecilia Gigena (epidemiological) [Ep 2 · 9:12](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=552)
- "The mantra for laparoscopic common bile duct exploration is all stones go forward, using balloons to dilate the sphincter and flush stones antegrade into the duodenum" — Luke Neff (clinical) [Ep 2 · 6:42](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=402)
- "If you're having to open up the common bile duct to extract the stone and you had ERCP capability, that's probably not the right thing to do in most cases" — Luke Neff (opinion) [Ep 2 · 7:30](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=450)
- "A 12 gauge angiocath is used for laparoscopic common bile duct exploration, with a new incision made to achieve a flat angle of entry into the cystic ductotomy" — Luke Neff (clinical) [Ep 2 · 9:37](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=577)
- "A 6 French ureteral stent cut down shorter for better flow is used with a glide wire, employing a cylinder technique to navigate the valves" — Luke Neff (clinical) [Ep 2 · 9:57](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=597)
- "An angioplasty balloon of 6 or 8 millimeters (but definitely not more than that) is used to dilate the sphincter" — Luke Neff (clinical) [Ep 2 · 10:37](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=637)
- "The balloon is inflated in the duct and pulled back to provide tactile feedback to locate the sphincter, then partially deflated to straddle the ampulla, then inflated to full profile under fluoroscopy and held for about 5 minutes" — Luke Neff (clinical) [Ep 2 · 11:02](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=662)
- "Never use a balloon larger than the dilated common bile duct because literature shows a higher rate of pancreatitis with ampullary dilation without sphincterotomy" — David Vitale (clinical) [Ep 2 · 11:23](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=683)
- "If the pancreatic duct is seen on fluoroscopy during the procedure, stop because that has a higher risk for pancreatitis" — Cecilia Gigena (clinical) [Ep 2 · 12:24](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=744)
- "The prevalence of stone disease is increasing" — Luke Neff (epidemiological) [Ep 2 · 12:34](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=754)
- "The learning curve for laparoscopic common bile duct exploration is around 5 to 10 cases, though this is person-specific" — Luke Neff (clinical) [Ep 2 · 13:40](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=820)
- "The position of the 12-gauge angiocath is really important, and the ability to manipulate the catheter and wire in the duct depends on the initial setup and how flat the angle of entry is into the cystic duct" — Luke Neff (clinical) [Ep 2 · 13:24](https://library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=804)
- "Dantes et al. performed a multi-center retrospective review of pediatric and adult patients treated for choledocholithiasis between 2018 and 2024" — Alex Halpern (epidemiological) [Ep 3 · 0:11](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=11)
- "724 patients were included in the study" — Alex Halpern (epidemiological) [Ep 3 · 0:22](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=22)
- "Surgery first approach with upfront laparoscopic cholecystectomy with intraoperative cholangiogram was performed in 201 pediatric patients and 169 adult patients" — Alex Halpern (clinical) [Ep 3 · 0:25](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=25)
- "Laparoscopic common bile duct exploration was attempted in 84 children and 140 adults in the surgery first group" — Alex Halpern (clinical) [Ep 3 · 0:35](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=35)
- "Common bile duct exploration success was higher in pediatric than adult patients" — Alex Halpern (clinical) [Ep 3 · 0:43](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=43)
- "Complication rates were similar between pediatric and adult patients in the surgery first approach" — Alex Halpern (clinical) [Ep 3 · 0:43](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=43)
- "A surgery first approach can be a safe and effective tool for managing choledocholithiasis in pediatric patients" — Alex Halpern (opinion) [Ep 3 · 0:49](https://library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patients-10122?t=49)
- "The study was a multi-center retrospective study conducted in the US from 2018 to 2022" — Cecilia Gigena (epidemiological) [Ep 1 · 0:09](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=9)
- "The study aim was to compare patients with suspected choledocholithiasis who underwent transcystic laparoscopic common bile duct exploration versus those who underwent ERCP first" — Cecilia Gigena (epidemiological) [Ep 1 · 0:09](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=9)
- "The study included 252 patients total" — Cecilia Gigena (epidemiological) [Ep 1 · 0:28](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=28)
- "156 patients were in group one (transcystic laparoscopic common bile duct exploration)" — Cecilia Gigena (epidemiological) [Ep 1 · 0:28](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=28)
- "96 patients were in group two (ERCP first)" — Cecilia Gigena (epidemiological) [Ep 1 · 0:38](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=38)
- "Patients in group one (transcystic laparoscopic approach) had significantly less complication rates compared to group two" — Cecilia Gigena (clinical) [Ep 1 · 0:38](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=38)
- "Patients in group one (transcystic laparoscopic approach) had lower length of stay compared to group two" — Cecilia Gigena (clinical) [Ep 1 · 0:38](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=38)
- "Attempting a transcystic laparoscopic common bile duct exploration may benefit pediatric patients with choledocholithiasis" — Cecilia Gigena (opinion) [Ep 1 · 0:52](https://library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-with-choledocholithiasis-8558?t=52)
- "Stone disease is increasing along with obesity in pediatric patients around the world, not just in the United States" — Em Gootee (host_summary) [Ep 4 · 0:52](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=52)
- "There are two main approaches for CBD stones requiring cholecystectomy: ERCP first followed by laparoscopic cholecystectomy, or surgery-first with IOC to identify and potentially remove stones during the same surgery" — Em Gootee (host_summary) [Ep 4 · 1:25](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=85)
- "The choice between surgery-first and ERCP-first depends on the setting and the surgeon's technical capabilities" (opinion) [Ep 4 · 1:50](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=110)
- "A surgery-first pathway reduces resource utilization, including MRCP" — Em Gootee (host_summary) [Ep 4 · 2:11](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=131)
- "ERCP adds potential morbidity, with a pancreatitis rate of 10% even when performed well" — Em Gootee (host_summary) [Ep 4 · 3:02](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=182)
- "If a surgeon cannot perform a cholangiogram, then ERCP is necessary if available" — Em Gootee (host_summary) [Ep 4 · 3:16](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=196)
- "Many pediatric surgeons lack confidence in intraoperative stone removal because they have been spoiled by ERCP availability and have done very few cases" (opinion) [Ep 4 · 3:23](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=203)
- "Pediatric surgeons need courses to learn the tricks of intraoperative stone removal" (opinion) [Ep 4 · 3:37](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=217)
- "If you know how to put in a central line and understand Seldinger technique, you can perform intraoperative stone removal" — Em Gootee (host_summary) [Ep 4 · 3:44](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=224)
- "With a surgery-first mindset, stone clearance rate reflected by negative IOC was 86%" — Em Gootee (host_summary) [Ep 4 · 3:50](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=230)
- "With simple adjuncts like advancing the catheter into the CBD or reaming the sphincter, success rate rises to the 90s" — Em Gootee (host_summary) [Ep 4 · 4:01](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=241)
- "For the 15% of unsuccessful cases, the plan is to clip the cystic duct, close, and have ERCP performed within the next day or two, or same-day in the OR if an endoscopist is available" — Em Gootee (host_summary) [Ep 4 · 4:17](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=257)
- "An endo-loop may be used instead of a clip when ERCP is planned, to facilitate subsequent endoscopic access" — Em Gootee (host_summary) [Ep 4 · 4:56](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=296)
- "The learning curve for intraoperative stone removal is manageable: the first few times are difficult, but after a few cases it becomes easier and even enjoyable" — Em Gootee (host_summary) [Ep 4 · 5:06](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=306)
- "The biggest key to success is having all necessary equipment in one place, because OR staff will not know what to get on the fly" — Em Gootee (host_summary) [Ep 4 · 5:15](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=315)
- "Success depends on IOC findings: a CBD chock full of 3-4 impacted stones is typically not amenable to surgery-first approach" — Em Gootee (host_summary) [Ep 4 · 5:26](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=326)
- "When flushing an impacted stone, there is a risk of inadvertently injecting contrast into the pancreatic duct, which can increase the risk of pancreatitis" — Em Gootee (host_summary) [Ep 4 · 6:03](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=363)
- "If the pancreatic duct lights up during flushing, that is a signal to slow down and be careful to avoid causing pancreatitis" — Em Gootee (host_summary) [Ep 4 · 6:15](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=375)
- "A study demonstrated 86% success rate for surgery-first, while the ERCP group had a 10% complication rate including cholangitis, bleeding, pancreatitis, and hemophilia" — Em Gootee (host_summary) [Ep 4 · 6:33](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=393)

## Changelog
- Sep 7: 1 item added automatically
- Sep 7: 3 items added automatically

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