From
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Update Course Rewind: Intraoperative Cholangiogram 2024
With Dr. Todd Ponsky · hosted by Dr. Min Gotti
Chapter 1 of 3 · Fundamentals
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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
Glucagon is given systemically during intraoperative cholangiogram procedures.
Some practitioners use lidocaine in the solution injected into the biliary tree to help relax the sphincter.
Balloon sphincteroplasty can be performed with a Fogarty catheter or a dedicated balloon.
While you can dilate the sphincter, it is crucial not to dilate beyond the diameter of the bile duct.
If you have a 5 mm bile duct and dilate it to about 10 mm, you're going to cause pancreatitis.
Not all IOCs are equal; sometimes you see things taper down to nothing (sludge), sometimes a well-defined meniscus, sometimes massive boulders and multiple stones.
Understanding the burden of disease in terms of stone size and number is really important for deciding next steps.
Intervention choices depend on local expertise, available tools, and who you work with in your hospital.
If you have multiple large stones, you will want to call your GI colleague.
When flushing, watch the stone carefully because if you flush and it starts floating up into the bile duct, you can turn a straightforward case into something much more complex if it moves into the intrahepatic ducts.
A stone moving into intrahepatic ducts results in a much more difficult ERCP and can get impacted there.
Doing more intraoperative cholangiograms and getting comfortable with interpreting them is important.
Building relationships with providers who will come to the operating room or see the patient after is important.
Taking the next step with IOC can reduce length of stay and hopefully the number of procedures these kids have to undergo.
The intraoperative cholangiogram session is classified as a green circle for established practice.
Dr. Neff typically uses a 50/50 mix of contrast and saline for all flushing maneuvers.
Dr. Neff learned a dilation technique from Dr. Jeff Polsky involving getting a waist in the balloon, holding to let it stretch slowly, coming up to profile in controlled fashion, and leaving it for 5 minutes to avoid rebound spasm of the sphincter.
35% of combined live and virtual audience voters wanted to see the intraoperative cholangiogram.
Controlled balloon dilation of the sphincter should never exceed bile duct diameter to avoid complications like pancreatitis.
Routine use of intraoperative cholangiograms and close collaboration with GI can reduce patient procedures and length of stay.