Choledocholithiasis with Drs. David Vitale & Lucas Neff
With Dr. David Vitale & Dr. Luke Neff · hosted by Dr. Cecilia Gigena · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Risk factors for choledocholithiasis include metabolic diseases, hemolysis such as sickle cell, and congenital biliary anomalies like choledochal cysts.
Choledocholithiasis is more common in older children, children with higher BMI, and patients of Hispanic ethnicity.
Retrospective data comparing ERCP versus laparoscopic common bile duct exploration is conflicted and the choice is institution-dependent and provider-dependent based on expertise.
Stones above the cystic duct pose a problem because they can float up during attempted laparoscopic removal, making a straightforward procedure much more difficult.
Local expertise and availability is the most important factor in the decision tree between ERCP and laparoscopic common bile duct exploration.
Dr. Neff uses a 12-gauge angiocath for access, which may be hard to find in pediatric hospitals but can be ordered.
The angle of entry into the cystic ductotomy should be as flat as possible, which is why a new incision is made rather than using existing ports.
Dr. Neff uses a 6 French urethral stent cut down shorter for better flow, with a glide wire inside, using a coaxial technique to navigate the valves of Heister.
Dr. Neff typically uses either a 6 millimeter or 8 millimeter angioplasty balloon, but definitely not more than that.
The balloon dilation technique involves inflating the balloon in the duct, pulling back for tactile feedback to locate the sphincter, partially deflating, straddling the ampulla, then going to full profile under fluoroscopy and holding for about 5 minutes.
Never use a balloon larger than the dilated common bile duct, as adult literature shows higher rates of pancreatitis with ampullary dilation without sphincterotomy.
After balloon dilation, Dr. Neff creates a seal on the distal common duct by partially inflating a balloon straddling the cystic duct-common duct junction so that flushing through the guide wire lumen gets pressurized downstream.
If laparoscopic common bile duct exploration is not successful, Dr. Neff places an endoloop on the cystic duct and refers to GI for ERCP.
The prevalence of stone disease is increasing.
The position of the 12-gauge angiocath is critical, 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.
The learning curve for laparoscopic common bile duct exploration is around 5 to 10 cases, though this is person-specific.
Choledocholithiasis stones may be made up of bile pigments or calcium and cholesterol salts.
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.
Patients with intermediate risk (abnormal liver biochemical tests or dilated common bile ducts) can undergo endoscopic ultrasound, MRCP, laparoscopic cholangiogram, or intraoperative ultrasound.
In pediatric literature, direct (conjugated) bilirubin more than 2 mg/dL was the most predictive factor for common bile duct stones.
Common bile duct diameter greater than 6 millimeters was most sensitive for predicting common bile duct stones in children, although without statistical significance.
The pediatric duct score (published in Journal of American College of Surgeons with 10 centers) identified three most predictive risk factors: ducts greater than 6 mm, common bile duct stones on ultrasound, or total bilirubin greater than 1.8 mg/dL.
Pediatric literature with small sample size shows that same-anesthesia laparoscopic cholecystectomy with ERCP in stone disease led to less anesthesia time and lower length of stay.
Randomized trials from 2013 show no significant difference in morbidity, mortality, retained stones, or failure rates between ERCP and laparoscopic common bile duct exploration.
Most free-standing children's hospitals do not have ERCP capabilities.
If the pancreatic duct is visualized during fluoroscopy, the procedure should be stopped due to higher risk for pancreatitis.