Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M. Gody 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 circle for established practice, blue square for promising newer practice, and black diamond for early adopter practice only. Today, Doctors David Vitale, Luke Neff, and Jeff Ponscip, will explain the surgery first mindset in pediatric biliary stone cases. This session is classified as a green circle for established practice. We have definitely seen anecdotally and in the literature, stone disease is really increasing along with obesity in in pediatric patients around the world. This is not just a United States issue. So I think this is an important topic for us to cover. All right, first clinical scenario. 15-year-old female, 24-hour history of colic right upper quadrant pain. Total bilirubin is 2.3. A little bit of an elevated lipase, not bad. Ultrasound is dilated. Uh, shows a dilated common bile duct at 1.9 cm. There is a stone that is visualized. What's our next step? There are essentially two main approaches when a patient has stones in the common bile duct, and also needs their gallbladder removed. One option is to perform an ERCP first to remove the ductal stones, followed by a laparoscopic cholecystectomy. The other option is to go straight to the laparoscopic cholecystectomy and perform an intraoperative cholangiogram to identify and potentially remove the stones during the same surgery. Everyone's saying surgery, what is disagreeing? Well, I don't disagree, but I think it depends in the setting in which you reside and your own technical capabilities. Now, we've had this discussion for 30 years. And I always come back to this one point. Not everyone in the world has the same capabilities as everyone else. We've just recently published some work showing that a surgery first pathway or at least that mindset and embracing that concept, really does reduce resource utilization including MRCP. Let's go to the actual answer. Surgery first. In this paper from the Journal of American College of Surgeons, the authors defined a very specific and predictive score for coalitis. And it's a great way to start a pathway. A lot of the times, before a gastroenterologist does the ERCP, the patient has had an ultrasound or they've had an MRCP. And we can utilize some of our predictive factors where we can go straight to doing a procedure if we need to, whether that be a combined procedure with a laparoscopic cholecystectomy and IOC and potentially call me into the room if an ERCP is needed. You have to add some depth and perspective to all of this. ERCP is a great procedure. I love to do it. It adds morbidity to a procedure, potential morbidity. And so we know that as good as you are at ERCP, you're going to get pancreatitis 10% of the time. If the surgeon can't do a cholangiogram, well, that ends the game. Then you need to do an ERCP if someone can do it. I don't feel I'm great at stone removal intraoperatively, because I've been so spoiled with the ERCP. I don't know the tricks. I've done very few in my career. So pediatric surgeons or general surgeons are have to step up our game and have to have courses somehow to learn all the tricks on how to get these stones out so I feel super confident. Sure. And I think if you know how to put in a central line and you understand the principles of Seldinger technique, then you can do this. In this paper published in JPS, they demonstrated that with a surgery first mindset, the stone clearance rate reflected by a negative intraoperative cholangiogram was 86%. If you just did flushing, if you just got that catheter a little bit more, just peek it in the common bile duct or maybe ring the sphincter, that success rate was in the 90s. So it doesn't take much. That's the dirty little secret is like, let's do something that that I think is accessible to everybody. 85% is terrific, but I think what may be intimidating to surgeons is is the 15% that are unsuccessful and what is your plan for that? Cuz that I think. You clip, you get out of there and you call your endoscopist. And do you do that in the OR? Do you If you have the availability. I mean, at Cincinnati they do, right? It depends on where you are and what you have. At our institution, they call me from the OR and they say, hey, come look at this IOC. We haven't been able to clear the duct. And most of the time we're able to run over there and do an ERCP pretty quickly. If you're in an institution where you don't have access to a doctor who can do ERCP, that's going to come running to your OR. You put a clip on it, you close up, maybe an end loop because you know the ERCP is going to happen and they go in within the next day or two. This is just an example pathway that came out of Vanderbilt. You can pause the video and review it in detail. The first couple times you do this with the wire and balloon and all that, you're going to hate it. After you've done a few, the learning curve, it's really actually kind of fun to do. According to Dr. Huntington, the biggest key to success is having all the necessary equipment in one place, because no one in the OR is going to know what to get it on the fly. I think it really depends on what you see on your IOC as well. If you've got a common biluct that's chalk full of three or four stones impacted there, you're not going to be able to be typically very successful with this type of surgery first. If you see signs of some other things, you may want to call your GI colleagues. Let's move on with the next case. We have an 8-year-old with sickle cell disease, elevated bilirubin. Baseline's around six, but this is, I don't know, 10 or 12, lipase is normal. MRCP reveals stones in the common bile duct. What is your next step? I think in our institution the lap coli is going to go first. There's going to be an intraoperative cholangiogram. They're going to potentially try to flush. Dr. Vitale cautions that when flushing, if a stone is impacted, there's a risk of inadvertently injecting contrast into the pancreatic duct, which can increase the risk of pancreatitis. And I think as soon as you start seeing that pancreatic duct light up, that is a signal to slow down on your flush, be careful because you can cause pancreatitis in these patients just by flushing contrast into that pancreatic duct with a stone. And so when you're attempting that method, make sure you're you're careful and watch out for that. This is another study demonstrating an 86% success rate. But the ERCP group had a 10% complication rate, including cholangitis, bleeding, pancreatitis, and hemobilia. In summary, a surgery first approach for pediatric colalithisis can be highly effective with stone clearance rates as high as 86% and reduce need for preoperative imaging like MRCP. The decision between surgery and ERCP depends on institutional resources and surgical skill. Early intraoperative cholangiogram with flushing can avoid ERCP related complications in many cases. Surgeons must be prepared for intraoperative challenges and have all necessary equipment on hand, while remaining cautious during flushing to avoid pancreatitis, especially when the pancreatic duct is inadvertently highlighted. Thank you for watching this video. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.