Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Update Course 2021: THORACOTOMY VS VATS FOR OSTEO METS
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The management of lung metastases in osteosarcoma may necessitate deciding approach–either thoracotomy or VATS. At the 2021 Pediatric Surgery Update Course, Dr. Anusua "Roshni" Dasgupta, MD reviewed the latest literature.
video · May 2022
Case-Based Journal Review: Cholelithiasis 2024
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It is already public knowledge that thousands of articles on different pathologies are published every day and that it is very difficult to follow them.
In this format we bring you a different way of knowing what is the most up-to-date o
podcast18:12 · Jul 2024
Choledocholithiasis with Drs. David Vitale & Lucas Neff
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In this episode, we're reviewing the management of choledocholithiasis with with Drs. David Vitale from Cincinnati Children's Hospital & Lucas Neff from Wake Forest Baptist.
Host: Dr. Cecilia Gigena
podcast15:27 · Jul 2024
Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024
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Welcome to the 12th Annual Update Course in Pediatric Surgery recap series, hosted by Dr. Em Gootee from Cincinnati Children’s Hospital. In this Green Circle (established practice) session, Drs. David Vitale, Luke Neff, and Jeff Ponsky expl
video7:31 · Jul 2025
StayCurrent Forums - Laparoscopic Cholecystectomy
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Jeffrey Ponsky, Professor Emeritus of Surgery and Nathaniel Soper, Chairman of Surgery, go back to the basics on Laparoscopic Cholecystectomy on this episode of the StayCurrent Forum.
video16:04 · Apr 2022
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Cholelithiasis management in pediatrics centers on timing of cholecystectomy and common bile duct (CBD) stone clearance strategy. For gallstone pancreatitis, early cholecystectomy (within 6 weeks) reduces recurrence from 60% to 2%, with no increase in biliary complications compared to delayed surgery [e8797-c2, e8797-c3, e8797-c5]. Risk stratification for choledocholithiasis uses validated predictors: CBD diameter >6mm, stones on ultrasound, or total bilirubin >1.8 mg/dL . The surgery-first approach—laparoscopic cholecystectomy with intraoperative cholangiogram and transcystic CBD exploration—achieves 86-90% stone clearance, reduces resource utilization, and avoids ERCP-associated pancreatitis (10% incidence) [e10706-c4, e10706-c6, e10706-c9, e10706-c10]. Technical success requires flat-angle cystic ductotomy access, coaxial wire/catheter technique through the valves of Heister, and balloon dilation (≤8mm, never exceeding duct diameter) held 5 minutes under fluoroscopy [e8884-c16, e8884-c17, e8884-c18, e8884-c19, e8884-c20]. ICG fluorescence (injected 12-15 hours preoperatively) enhances biliary visualization but comparative data are confounded by era effects [e5417-c3, e8797-c18, e8797-c19]. ERCP remains first-line for impacted stones with rising lipase/jaundice or when surgical expertise is unavailable [e8797-c11, e10706-c14]. Institutional capabilities and local expertise drive pathway selection more than evidence hierarchy .
- Early cholecystectomy (within 6 weeks of gallstone pancreatitis) reduces recurrence to 2% versus 60% with delayed surgery, without increasing complications. [e8797-c2, e8797-c3, e8797-c5]
- Surgery-first approach (laparoscopic cholecystectomy with intraoperative cholangiogram and transcystic exploration) clears CBD stones in 86-90% of cases, avoiding ERCP's 10% pancreatitis risk. [e10706-c4, e10706-c6, e10706-c9, e10706-c10]
- Validated pediatric risk score identifies high-probability CBD stones: duct >6mm, stones on ultrasound, or total bilirubin >1.8 mg/dL warrant preoperative imaging or ERCP. [e8884-c8]
- Transcystic balloon dilation technique: flat-angle access, coaxial wire navigation, balloon ≤duct diameter, 5-minute inflation straddling ampulla. Stop if pancreatic duct opacifies. [e8884-c16, e8884-c17, e8884-c19, e8884-c23]
- ICG fluorescence (12-15 hours preoperative) improves biliary visualization but requires institutional infrastructure; pathway choice depends on local ERCP/surgical expertise availability. [e5417-c3, e8884-c13, e10706-c3]
For patients & families
Gallstones in children are becoming more common, especially in older kids and those with higher weight [e8797-c1, e8884-c3, e10706-c1]. When a stone gets stuck in the bile duct connecting the gallbladder to the intestine, it can cause serious pain and inflammation of the pancreas . Doctors have learned that removing the gallbladder soon after this happens—rather than waiting weeks—prevents the problem from coming back; in one study, only 2% of children had another episode when surgery happened early, compared to 22% when it was delayed, and 60% when delayed more than six weeks [e8797-c2, e8797-c3]. Surgeons now have better tools to see the bile ducts during surgery, including a special green dye (ICG) that lights up under a camera, making it easier to identify important structures and avoid injury [e5417-c2, e5417-c3, e8797-c18]. There are two main approaches when stones are stuck in the duct: a scope procedure (ERCP) to remove them first, or surgery first with techniques to flush or remove stones during the operation . Studies show that when surgeons try to clear the duct during the gallbladder operation, it works 86-90% of the time and may result in fewer complications overall [e10706-c9, e10706-c10, e8797-c13]. The choice depends on what expertise is available at each hospital .
Gallstones in children are becoming more common, especially in older kids and those with higher weight [e8797-c1, e8884-c3, e10706-c1]. When a stone gets stuck in the bile duct connecting the gallbladder to the intestine, it can cause serious pain and inflammation of the pancreas . Doctors have learned that removing the gallbladder soon after this happens—rather than waiting weeks—prevents the problem from coming back; in one study, only 2% of children had another episode when surgery happened early, compared to 22% when it was delayed, and 60% when delayed more than six weeks [e8797-c2, e8797-c3]. Surgeons now have better tools to see the bile ducts during surgery, including a special green dye (ICG) that lights up under a camera, making it easier to identify important structures and avoid injury [e5417-c2, e5417-c3, e8797-c18]. There are two main approaches when stones are stuck in the duct: a scope procedure (ERCP) to remove them first, or surgery first with techniques to flush or remove stones during the operation . Studies show that when surgeons try to clear the duct during the gallbladder operation, it works 86-90% of the time and may result in fewer complications overall [e10706-c9, e10706-c10, e8797-c13]. The choice depends on what expertise is available at each hospital .
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
Update Course 2021: THORACOTOMY VS VATS FOR OSTEO METS
In adult centers, surgeons perform 100 to 300 cholecystectomies per year compared to 10 to 30 per year in pediatric centers
epidemiologicalChiro Esposito3:34 ↗
ICG is a soluble molecule that rapidly binds to albumin and is removed from circulation by the liver into bile juice
clinicalChiro Esposito0:23 ↗
For cholecystectomy, ICG must be injected 12 to 15 hours preoperatively to allow secretion into bile juice for selective biliary tree visualization
clinicalChiro Esposito7:15 ↗
If ICG is injected intraoperatively for cholecystectomy, the liver takes up the dye and appears green, making gallbladder identification difficult
clinicalChiro Esposito7:51 ↗
For all ICG indications except cholecystectomy (kidney, varicocele, lymphoma, tumors), the injection is given intraoperatively
clinicalChiro Esposito7:51 ↗
ICG vial contains 25 mg in 4 ml, diluted with 10 ml sterile water, with 6 ml injected intravenously for cholecystectomy
clinicalChiro Esposito4:40 ↗
For partial nephrectomy in duplex kidney, ICG is injected three times: via ureteral catheter to identify normal ureter, intravenously to visualize kidney vasculature, and intravenously again after vessel clipping to show devascularization line
clinicalChiro Esposito9:34 ↗
In duplex kidney with reflux, the two ureters are attached to each other, making identification of the normal ureter difficult without ICG
clinicalChiro Esposito9:34 ↗
For varicocele repair, intratesticular injection of 2 ml ICG solution allows intraoperative fluorescence lymphography to identify and spare lymphatic vessels
clinicalChiro Esposito17:30 ↗
Palomo varicocele repair has success rate of more than 97-98% but ligating lymphatics in the spermatic bundle causes postoperative hydrocele in about 20% of cases
clinicalChiro Esposito17:30 ↗
In a series of more than 150 varicocele patients using ICG lymphatic sparing technique, there were zero postoperative hydroceles
clinicalChiro Esposito19:10 ↗
The spermatic bundle contains three to four lymphatic vessels
clinicalChiro Esposito17:30 ↗
There is no maximum dose limit for ICG based on adult surgery studies
clinicalChiro Esposito21:53 ↗
ICG vial remains usable for six hours after preparation
clinicalChiro Esposito21:24 ↗
No adverse effects of ICG were observed in the presenter's experience
clinicalChiro Esposito21:24 ↗
ICG technology can be used in both laparoscopy (requiring special camera and optic) and robotic surgery with Da Vinci XI Firefly system
clinicalChiro Esposito1:20 ↗
The newer Rubin ICG system allows visualization in color with biliary tree appearing green, compared to older systems showing black and white images
clinicalChiro Esposito5:40 ↗
For elective cholecystectomy cases, patients are hospitalized the day before surgery for ICG injection in the late afternoon if surgery is scheduled early morning
clinicalChiro Esposito8:42 ↗
ICG technology helps reduce complications in laparoscopic cholecystectomy, particularly beneficial for trainees and in centers with longer learning curves due to lower case volumes
opinionChiro Esposito3:34 ↗
Case-Based Journal Review: Cholelithiasis 2024
Chile has the highest rate of cholelithiasis globally
epidemiologicalJose Campos1:07 ↗
In a multi-center study of 167 early cholecystectomy patients versus 79 delayed, early cholecystectomy had 2% recurrence of pancreatitis compared to 22% in delayed surgery
Host summaryCecilia Gigena summarizes what Dr. Jose Campos said — not the host's own clinical position3:11 ↗
When cholecystectomy was delayed more than 6 weeks after gallstone pancreatitis, recurrence rate increased to 60%
Host summaryCecilia Gigena summarizes what Dr. Jose Campos said — not the host's own clinical position3:36 ↗
Even in patients with no stones remaining, 2% will get recurrent pancreatitis from the initial insult
clinicalTodd Ponsky3:44 ↗
Patients who underwent early cholecystectomy did not have more biliary complications than delayed surgery patients
Host summaryCecilia Gigena summarizes what Dr. Jose Campos said — not the host's own clinical position4:27 ↗
When patients present with gallstone pancreatitis, most pain and elevated enzymes occur as the stone is passing, and symptoms often resolve overnight as the stone passes
clinicalTodd Ponsky5:01 ↗
If laboratory values normalize after gallstone pancreatitis, ERCP is not indicated, but intraoperative cholangiogram should be performed to check for additional stones
clinicalTodd Ponsky5:36 ↗
A Western Pediatric Surgery Research Consortium machine learning algorithm based on 1600 patients from 10 centers (2016-2019) can predict common bile duct stones using nine clinical factors, with 20% of patients having CBD stones
Host summaryEm Gootee summarizes what Dr. Jose Campos said — not the host's own clinical position6:26 ↗
The machine learning algorithm for predicting CBD stones has a negative predictive value of 98%, meaning only 2% chance of missing stones when algorithm predicts low risk
Host summaryJose Campos summarizing a resource — not the host's own clinical position7:11 ↗
The previous algorithm for predicting CBD stones was based on 300-400 patients, compared to 1600 in the new algorithm
Host summaryEm Gootee summarizes what Dr. Jose Campos said — not the host's own clinical position7:33 ↗
For patients with impacted stone, rising lipase, and worsening jaundice, ERCP is preferred because surgeon confidence in retrieving impacted stones intraoperatively is lower
opinionTodd Ponsky8:58 ↗
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