Update Course Rewind: Intraoperative Cholangiogram 2024

Globalcast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Min Gotti from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year, we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories. Green circles were established practices, blue squares for promising newer practices, and black diamonds for early adopter practices only. Here, doctors David Vitale, Luke Neff, and Jeff Polsky will teach us intraoperative colangram, techniques and pitfalls. This session is classified as a green circle for established practice. Okay, unsuccessful common duct exploration. You you decide to flush and get some glucagon. For those that have adopted this or started to dabble in this. Um you do see contrast in the duodenum on the intraoperative colangram. What do you do next? The question is, how should we handle flushing during the intraoperative colangram? And what is our approach to using glucogon? We're actually giving the glucagon systemically. Some people are are using a little bit of lidocaine in the actual thing that's injected into the biliary tree, thinking that may help relax things. Dr. Neff typically uses a 50/50 mix of contrast and saline for all of his flushing maneuvers. I usually do a balloon sphincteroplasty and then try to flush it out still. Okay. You can do that with the Fogerty or you can actually get the balloon. So you like to see grab a balloon, grab a spy glass, okay. Please call GI. It'll depend on what you have available to you. One important point to emphasize, while you can dilate the sphincter, it is crucial not to dilate beyond the diameter of the bile duct. So if you got a 5 mm bile duct and a stone that's so obstructive, you got to be careful if you dilate that duct to about 10 mm, you're going to cause pancreatitis. Here, Dr. Neff shares that he learned a valuable technique on dilation maneuver from Dr. Jeff Polsky. Ever since you said this, we've been employing this, but it's the idea that come up, get a little bit of a waist in the balloon and just hold. Let that thing stretch slowly and then you come up to profile in a very controlled fashion and leave it there for a while. We've been leaving that for 5 minutes to avoid that rebound spasm of the sphincter. According to our poll results from the combined live and virtual audience, 35% of voters wanted to see the intraoperative colangram or IOC. Not all IOCs are equal. We're trying to define that because sometimes you just see things taper down to a little nothing and that's just sludge. Sometimes you see a very well-defined meniscus, sometimes you have these like massive boulders and multiple of them. It've been in children. And so I think a really important thing is like what do you have available to you? You've done a flush maneuver, you may want to take the next step, you may want to grab a balloon. And I think understanding what you're dealing with in terms of the the burden of disease is really important. What if you have multiple large stones, then you will want to call your GI colleague. The other thing when you're flushing, make sure you watch that stone because if you flush that stone and it starts floating up into the bile duct. And if you're not paying close attention, you can turn a very straightforward case, a stone sitting in the common bile duct into something much more complex if it moves into the intrahepatic ducts. Which is a much more difficult ERCP, it can get impacted there. The the bottom line is I think yeah, doing more intraoperative colangram, getting comfortable with it, interpreting it. It's important to build the relationships with the providers who's going to come to the operating room or will see the patient after. And taking the next step to really try to reduce length of stay and hopefully the number of procedures these kids have to go under. And a lot of this is going to depend on local expertise, what you have available to you, who you work with in your hospital. All these things are very, very important. In summary, controlled balloon dilation of the sphincter should never exceed that bile duct diameter to avoid complications like pancreatitis. The choice of intervention, flush, balloon, or ERCP depends on the size and number of stones as well as available tools and expertise. Routine use of intraoperative colangrams and close collaboration with GI can reduce patient procedures and length of stay. Thank you for watching this video. Globalcast MD along with Cincinnati Children's Hospital sharing knowledge to improve