Surgery-first approach for pediatric biliary stones and common bile duct management

Stone disease is increasing along with obesity in pediatric patients around the world, not just in the United States.

There are two main approaches for patients with common bile duct stones who need cholecystectomy: ERCP first followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with intraoperative cholangiogram to identify and potentially remove stones during the same surgery.

A surgery-first pathway reduces resource utilization, including MRCP.

A predictive score for cholelithiasis published in the Journal of American College of Surgeons can help guide pathway decisions.

If a surgeon cannot perform a cholangiogram, then ERCP is necessary if someone can do it.

If you understand central line placement and Seldinger technique principles, you can perform intraoperative stone removal.

In a JPS paper, surgery-first approach achieved 86% stone clearance rate with negative intraoperative cholangiogram.

With simple additional maneuvers like advancing the catheter into the common bile duct or reaming the sphincter, stone clearance success rate reaches the 90s.

For the 15% of unsuccessful cases, the surgeon clips or places an endo loop, closes, and arranges ERCP within the next day or two.

At Cincinnati Children's, when surgeons cannot clear the duct, they call the endoscopist to the OR and ERCP is performed quickly in most cases.

According to Doctor Huntington, 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.

If the common bile duct has 3-4 impacted stones on IOC, surgery-first is typically not very successful.

Doctor Vitale cautions that when flushing with an impacted stone, there is risk of inadvertently injecting contrast into the pancreatic duct, which can increase pancreatitis risk.

When the pancreatic duct lights up during flushing, this is a signal to slow down because you can cause pancreatitis by flushing contrast into the pancreatic duct with a stone present.

A study demonstrated 86% success rate for surgery-first, while the ERCP group had 10% complication rate including cholangitis, bleeding, pancreatitis, and hemophilia.