Case-Based Journal Review: Cholelithiasis 2024

Hello everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Gena and I'm E. Goddy, and we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we're sharing knowledge to improve child health around the globe. So today, we have another episode of the Case-based Journal Review. So to remind you what this Yes we are working with Doctor Jose Campos. Hi, I'm Jose Campos. I work in Roberto El Rio Hospital in in Chile. I'm also leading a group of volunteers called Journal Hive and we try to bring you the best of pediatric surgery literature to you. I'm with Doctor Todd Ponsky, a pediatric surgeon and the chief. Innovation officer here at Cincinnati Children's and what we do is we go through a case and discuss the latest updates in the literature about the specific pathology to help treat this patient in a better way. And today I'm super excited about this podcast. We haven't done one in a while that's reason number one. But also I'm super excited about this podcast because Chile is the country with the highest rate of cholelithiasis, so this is something we we can actually say something. So let's start. We have a 12 year old female with acute gallstone pancreatitis admitted overnight. So for this patient, do we do an index admission cholecystectomy or a delayed surgery? It really depends on the patient and the situation. And that was Doctor Todd Pomsky. I typically do it before they go home, and I have not found. That it's prohibitively difficult in most cases to do the operation. I call this a little bit of the history of the cool-off period. And in case you forgot, that was Dr. Jose Campos. We always favor for an index admission surgery, but they always told me if their symptoms have been going on for too long, just let the pancreatitis heal for a time at home and then bring the patient back, and that threshold was around the 7 to 10 day mark. And then when I went back to pediatric surgery, that threshold was around the 2 to 3 day mark for them, and it was very difficult for me to convince them on doing index and admission surgery. Well, maybe this first article of today can help you to convince them. First article is index admission cholecystectomy and recurrence of pediatric gallstone pancreatitis, multi-center cohort analysis. So this is The paper that came in Journal of the American College of Surgeons. It's a multi-center retrospective review of pediatric patients with gallstones, pancreatitis between 2010 and 2017, and their aim was to compare the recurrence rates of pancreatitis, also compare outcomes and complications between patients undergoing early cholecystectomy, meaning during the index. Admission and those who underwent delayed surgery, which was those who haven't received surgery at the moment of the study, or it was done after discharge. They had 167 underwent an early cholecystectomy and 79 underwent a delayed cholecystectomy. The general outcome is that patients who underwent the early cholecystectomy. Had only 2% of recurrence pancreatitis compared to 22% in patients doing a delayed surgical approach. Interestingly, if they waited more than 6 weeks, the recurrence rate went up to 60%. So 2% of the time in patients, even if they have no stones, they will get recurrent pancreatitis from their initial insult, whereas 60% if you wait 6 weeks. That is. So provocative. That is so clear cut that nobody should be debating this anymore. That's what I was going to say. Like, first you said if I have a reliable patient, but this changes my approach. Not even the reliable patient, we should send them home without their gallbladder removed. And I think we still need to see on the skill of the surgeon, and still we need to think of the severity of the illness to individualize this information, but for the vast majority of gallstone pancreatitis, I think this should be the strategy. Yes, and one. The thing that it's important too is that patients who underwent the early cholecystectomy didn't have more biliary complications. That's a great point, really good point, because the fear of going in early was doing more damage than benefit, and that is not proven in this article. Yeah, are we ready for the second question? Yeah, so let's say pancreatitis is resolved and you're ready to operate on the patient. Can you predict the risk of cholecoatasis in this patient? So what do you think about this, Todd? So, interestingly, when patients come in with gallstone pancreatitis and they have all of this pain, most of the time, the symptoms of the pain and the elevated enzymes are as the stone is passing. So, it's interesting that if you wait till the next day, You find resolution because the stone often has passed. Now there might be other stones, but oftentimes these will pass overnight. Would you go in a relaxed mode to a lab call directly to this patient, or would you do something? What, what, what, what would you do? So if your numbers normalize, I do not do ERCP. I will do an intraoperative changiogram to make sure there's not another stone, but I would not do an ERCP if their numbers normalize. And let's hear what Doctor Jose Campos had to say. So the, the situation, you don't want to be in is you book a case as a simple lab cole, no introvertative cholangiogram. You didn't think of an MRCP or ERCP or anything, and then boom, you find the stone there. That's what we want to avoid. So, so how I dealt with the situation before, if they had no alteration at all, no history of cholangitis or pancreatitis, I would just do a lab cole and nothing else. But if there was any alteration whatsoever, I would just do an MRCP and if it's positive, do an ERCP. So, that's why I brought this article. So, this article is coming from Western Pediatric Surgery Research Consortium. It's a retrospective study and they looked at machine learning to predict pediatric cholitic lithiasis and this article was published in 2023 in the surgery journal. Their main question was, is it possible to predict the risk of common bile duct stones preoperatively. It's a multi-center, included 10 different centers. Between 2016 to 2019 they had nearly 1600 patients. 20% of them had common bile duct stones, and they were able to look for nine most important clinical factors. Their result is, yes, we can predict and let's use this model. The negative predictive value of this algorithm is 98%. That means that you're gonna be in that nasty situation, uh, if, uh, only 2% of the time if you trust this algorithm. So that's why I think this is the one to use, and I don't think we can get more precise than this algorithm in terms of predicting CBDs tolls pre preoperatively. It has a decent amount of patient population too. I think the previous algorithm was around 300 to 400 patients. This one has 1600. Uh, it's just so exciting to see we finally trying to create. Create algorithms and trying to implement in our daily practice to be able to precise decisions. But would you trust this algorithm and just don't do an introperative angiogram with a risk of 2%? I think it's very compelling based on what you guys all just said that there's a huge patient population that they studied in. They developed an algorithm that has a 98% negative predictive value. They tested the algorithm afterwards. All of those things coming together, I could be convinced to change my practice and not do a routine intraoperative cholangiogram if this score showed that there was only a 2% chance I was wrong. So, we determined with this algorithm that there's a high risk of keleticcholithiasis and what is your approach? Do, I think we talked a little bit about this, but basically is, do you do ERCP first or do you approach a laparoscopic byact exploration? So, there's a lot of, it depends situations here. It depends on your center, it depends on the capabilities. If it's a combined pediatric adult center. And again, and that was Todd. If I have a patient that comes in with an impacted stone, and their lipase is elevated, the next day their lipase goes up even more, they're, they're getting more and more jaundiced, they're getting worse, I would send them for ERCP because I don't know how good I am at retrieving impacted stones. That is different than if I had an ultrasound reading saying, That there was a stone in the common bile duct. Cause that I would feel confident that I would probably be able to remove. So, in our training, we need to have courses or training on newer techniques of getting those stones out intraoperatively. And Luke Neff has that new device that I've never used, but apparently is also good. So I think I would do an intraoperative angiogram, but I do need to get better at learning all these new techniques of stone removal. And we thought of what Todd said here, so we include a session at the next update course this August 2024. So if you don't want to miss this, don't forget to subscribe to this year update course in the link below. I already said my option. And again, that was Dr. Jose Campos. Initially did MRCP and ERCP preoperatively that was in a hospital where we had those tools available 24/7, but then with the cost with the increased length of stay of of waiting, the alternative of of laparoscopic common bile duct exploration, it's, it's looking more and more interesting. So I think it's time to maybe, maybe with this article relearn those skills and and get it to the to the OR again. OK, so let's go to the 3rd article of the day. Funny you mentioned it, uh, Todd, because this comes. From Luke Neff's team. So this is a transcystic laparoscopic common by lab exploration for pediatric patients with cholelithiasis. It is a multi-center retrospective cohort study done between 2018 to 2022, and their aim was to compare the outcomes between the two different patients. The OR first, meaning patients who underwent laparoscopic cholecystectomy, plus the intraoperative cholangiogram. And according to the results, they can go for laparoscopic columbi duct exploration, and if that fails, then an ERCP and then we compare to the second group that is first an ERCP and then a laparoscopic cholecystectomy. So they have 252 patients, 156 underwent the laparoscopic cholecystectomy with the intraoperative cholangiogram 1st, and 96 underwent the ERCP first. And what Found is that patients who underwent the intraoperative cholangiogram had less complications and shorter length of stay, and of them 86% of the patients only needed that surgery. I, I really love this study because you said it requires a lot of skills, but this is not just a single center, one expert surgeon showing off what they can do. This is 4 centers, so the range of surgeons that are doing this, it's, it's. Quite broad, so this article is trying to say it's feasible. The other myth that gets debunked was that, uh, if you do an ERCP post, the common bile duct is going to explode. You're gonna have a leak, etc. No, the the 14% patients that had an ERCP post, they were doing just fine in this article. They do a stepwise approach of all the patients that had only a, a flush, a saline flush through the urethral stent, 84% of them got cleared. I agree with what you're saying. I'm saying there's two points to be made. One is we should go try it because most of the time you can clear it. But two is I wish I knew how to be better at removing the ones that don't flush through. And this is something that actually would be an effectively taught thing in a lab. OK, so patient is booked for surgery tomorrow. Would you use ICG? So here's an example of where I am old and washed up. The answer to this should be yes. I just don't have as much experience as my younger colleagues. So. This is published in 2023 October in the Signing Green Fluorescent cholangiography, the new standard practice to perform laparoscopic cholecystectomy in pediatric patients, a comparative study with conventional laparoscopic technique. Basically, they're trying to answer is ICG, uh, lab collie is better than the standard one, and they had 10 years from 2013 to 2023, they performed 173 lab collies. They had 83 patients with standard technique and 90 patients with ICG. In conclusion, they saw the periodic complication rate was. Significantly higher in standard technique, 12% compared to 0%. Overall length of surgery, length of cystic duct isolation, clipping, and time of gallbladder removal were significantly longer in the standard technique, and the visualization rate of complete biliardry was significantly higher. And let's hear what Doctor Jose Campos had to say. I, I don't like this study a lot to call it the new standard practice. I think with you too much. There's several key points here, so they're comparing different times and in different times so many things change like you get better with surgery, the instruments. Get better, so I don't think they're comparing ICG versus non-ICG. Secondly, they put all the complications in the same bags. They don't even report common bile duct lesion as a separate thing, and I don't think bleeding, it's attributable to having or not having ICG. And then again, having a group of patients with zero complications, that again, it's, it's kind of a red flag for me. I agree with you. I am skeptical of papers that claim that something is now the new standard just because it's become their new standard. It doesn't. Necessarily mean that it's recommended as the standard of care. So that's, that immediately made me question the paper. It's a shame because I do think this is a very exciting new technology. But if it's intravenous, I actually am compelled that you just eliminated the need for instrumentation, which is a big deal. That's also an important point, Todd. They're not comparing ICG compared to intraparative cholalangiogram. They're comparing ICG versus nothing versus just simple visualization. So of course, of course your endpoint is going to be, of course you see more if you use a technique to visualize more structures. I think we should be learning about ICG. I mean this is provocative for me to say, Todd, come on, get with it. Like this is something you should probably learn. I don't know how to learn it. And, and I do think it's a good study. I, I mean, I do think it's good that this study was published because it opened up our eyes that we should be paying attention to ICG. There's almost no downside to it. It's just a matter of, is it really as much of the holy grail that this article says it is. Great. So, now it's time to summarize. So first, we talked about index admission cholecystectomy versus delayed surgery, and we find out that waiting for 6 weeks to do a cholecystectomy after an acute gallstone pancreatitis can lead to a 60% recurrence instead of a 2% recurrence. Then we talk about the algorithms to predict cholecholithiasis, and we find out that there's a new algorithm that can predict choletocholithiasis with a great success rate. So we probably wanna use that in our patients before doing a lab cholecystectomy. Then we talk about choletocholithiasis and how to approach them. With an intraoperative cholangiogram and if needed, a laparoscopic common bile duct exploration or an ERCP. And what we find out is that if we have the resources, we can go for an ERCP first. But we need to learn more on how to do a laparoscopic common bile duct exploration because that can help our patients to reduce their length of stay in the hospital and to avoid a second surgery. Last but not least, we talk about ICT and how that helps us to visualize more the biliary retreat, but doesn't necessarily change the outcomes in our patients. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.