Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024

The Presentation

A 15-year-old girl presented with 24 hours of colicky right upper quadrant pain 0:52. Her total bilirubin was 2.3, lipase mildly elevated, and ultrasound showed a dilated common bile duct at 1.9 cm with a visible stone [case1]. The question was not whether she needed intervention — it was which intervention to do first.

The Decision Point

Two pathways exist for common bile duct stones requiring cholecystectomy 1:25. The traditional approach: ERCP first to clear the duct, then laparoscopic cholecystectomy days later. The alternative: proceed directly to laparoscopic cholecystectomy with intraoperative cholangiogram, attempt stone clearance during the same operation, and reserve ERCP for failures. The choice hinges on the surgeon's technical capability and institutional resources 1:50, but the surgery-first pathway reduces resource utilization — including the need for MRCP — and consolidates care into a single anesthetic event 2:11.

ERCP carries a 10% pancreatitis rate even when performed well 3:02. For a straightforward case like this one, that risk is avoidable. If the surgeon cannot perform an intraoperative cholangiogram, ERCP becomes necessary 3:16. But many pediatric surgeons lack confidence in intraoperative stone removal not because the technique is difficult, but because ERCP availability has left them undertrained 3:23. One discussant admitted plainly: "I don't feel I'm great at stone removal intraoperatively because I've been so spoiled with ERCP. I don't know the tricks. I've done very few in my career" [q1]. The technical barrier is lower than perceived. If you can place a central line and understand Seldinger technique, you can do this 3:44.

What They Did

The team proceeded with laparoscopic cholecystectomy and intraoperative cholangiogram. With a surgery-first approach, stone clearance reflected by negative IOC succeeds in 86% of cases 3:50. Simple adjuncts — advancing the catheter into the CBD, flushing with controlled pressure, reaming the sphincter — push success rates into the 90s 4:01. The learning curve is manageable: the first few attempts are difficult, but after a handful of cases the technique becomes routine and even enjoyable 5:06. The critical preparation is logistical, not technical. Success depends on having all necessary equipment assembled in one place, because OR staff will not know what to retrieve on the fly 5:15.

For the 15% of cases where intraoperative clearance fails, the plan is straightforward: clip the cystic duct, close, and proceed to ERCP within the next day or two — or same-day in the OR if an endoscopist is available 4:17. An endo-loop may be used instead of a clip when ERCP is anticipated, to facilitate subsequent endoscopic access 4:56. The surgery-first approach does not eliminate ERCP; it reserves it for cases that need it.

The Caveat

IOC findings determine feasibility. A CBD packed with three or four impacted stones is typically not amenable to surgery-first clearance 5:26. In those cases, calling for ERCP is the correct decision. The other risk is inadvertent pancreatic duct injection during flushing. When a stone is impacted and you flush contrast under pressure, the contrast can reflux into the pancreatic duct, increasing pancreatitis risk 6:03. If the pancreatic duct lights up on fluoroscopy, that is a signal to slow down and reduce flush pressure 6:15. "I think as soon as you start seeing that pancreatic duct light up, that is a signal to slow down on your flush, be careful because you can cause pancreatitis" [q4].

What the Case Changes

A published series demonstrated 86% success for surgery-first, while the ERCP group had a 10% complication rate including cholangitis, bleeding, pancreatitis, and hemophilia 6:33. The surgery-first pathway is not about eliminating endoscopy — it is about reserving it for failures rather than leading with it. For the majority of pediatric CBD stones, a single operation with intraoperative cholangiogram and simple clearance techniques avoids a second procedure, a second anesthetic, and the baseline morbidity of ERCP. The technical skill required is accessible to any surgeon comfortable with wire-based techniques. The barrier is not capability — it is habit.

The Presentation

A 15-year-old girl arrived with 24 hours of colicky right upper quadrant pain 0:52. Her total bilirubin was 2.3 with mildly elevated lipase. Ultrasound showed a dilated common bile duct measuring 1.9 cm with a visualized stone. The question was not whether she needed intervention — she clearly did — but which intervention to perform first.

The Decision Point

Two pathways exist for CBD stones requiring cholecystectomy: ERCP first to clear the duct followed by laparoscopic cholecystectomy, or surgery-first with intraoperative cholangiogram to identify and potentially remove stones during the same operation 1:25. The choice depends on the setting and the surgeon's technical capabilities 1:50. ERCP, while effective, carries a 10% pancreatitis rate even when performed well 3:02. A surgery-first pathway reduces resource utilization, including MRCP 2:11, but requires the surgeon to be comfortable with intraoperative stone management.

The discussants acknowledged a competency gap. One stated: "I don't feel I'm great. At stone removal intraoperatively because I've been so spoiled with ERCP. I don't know the tricks. I've done very few in my career, so pediatric surgeons or general surgeons. I have to step up our game and have to have courses somehow to learn all the tricks on how to get these stones out, so I feel super confident" [q1]. Many pediatric surgeons lack confidence in intraoperative stone removal because ERCP availability has limited their experience 3:23. Yet the technical barrier may be lower than perceived. Em Goddy noted: "if you know how to put in a central line and you understand the principles Singer technique, then you can do this" [q2].

What They Did

The team advocated surgery-first: laparoscopic cholecystectomy with intraoperative cholangiogram. With this approach, stone clearance reflected by negative IOC was 86% 3:50. Simple adjuncts — advancing the catheter into the CBD or reaming the sphincter — raised success rates into the 90s 4:01. The biggest key to success is having all necessary equipment in one place, because OR staff will not know what to retrieve on the fly 5:15.

Success depends on IOC findings. A CBD chock full of 3-4 impacted stones is typically not amenable to surgery-first 5:26. 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 4:17. An endo-loop may be used instead of a clip when ERCP is planned, to facilitate subsequent endoscopic access 4:56.

A second case illustrated a specific risk. An 8-year-old with sickle cell disease presented with elevated bilirubin — baseline around 6, now 10-12 — and normal lipase. MRCP revealed CBD stones. During surgery-first management with IOC and attempted flushing, there is a risk of inadvertently injecting contrast into the pancreatic duct when a stone is impacted, which can increase the risk of pancreatitis 6:03. Goddy cautioned: "I think as soon as you start seeing that pancreatic duct light up, that is a signal to slow down on your flush, be careful because you can cause pancreatitis" [q4]. If the pancreatic duct lights up during flushing, that is a signal to slow down and be careful to avoid causing pancreatitis 6:15.

The Outcome

The discussants did not report specific outcomes for these cases. They presented a study demonstrating 86% success rate for surgery-first, while the ERCP group had a 10% complication rate including cholangitis, bleeding, pancreatitis, and hemophilia 6:33.

What the Case Changes

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 5:06. Pediatric surgeons need courses to learn the tricks of intraoperative stone removal 3:37. If a surgeon cannot perform a cholangiogram, then ERCP is necessary if available 3:16. The surgery-first mindset is not about eliminating ERCP — it is about reserving it for the 10-15% who need it rather than exposing all patients to its morbidity. The threshold question is not whether you can clear every duct, but whether you can recognize on IOC which ducts you cannot clear, clip them, and arrange next-day ERCP without harm.