Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 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. In this video, Doctors David Vitalle, Luke Kneff, and Jeff Ponsky will talk about how to prevent gallstone pancreatitis in pediatric biliary stone cases. This session is classified as a green circle for established practice. This is a 16-year-old male. This is actually a patient of mine from about four months ago. This patient, currently undergoing treatment for acute lymphoblastic leukemia, or ALL, presents with right upper quadrant pain. He's neutropenic, has markedly elevated liver function tests, and ultrasound findings are consistent with acute cholecystitis and choledocholithiasis. So now we have a little bit more of a different situation with the neutropenic thrombocytopenic patient. What are we going to do? According to our live and virtual audience poll, over 50% opted to start antibiotics and address the elevated liver function tests. And that's the exact approach Dr. Kneff took. And he spontaneously passed the stone. LFTs came back down. We were able to get him, his counts recovered and get him to elective cholecystectomy. Um, I want to bring up one other scenario too for the audience, which is gallstone pancreatitis, which I think is a little bit different than our conventional show up with a stone in the duct. Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can also impede pancreatic drainage. This blockage prevents pancreatic enzymes from reaching the small intestine, leading them to accumulate and damage the pancreas. So the question is, how would you manage this patient? In my experience, some surgeon will go in and say, hey, we're going to do the cholecystectomy within a few days. Some will say, hey, we're going to wait for a week. From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this case right away. So just want to hear from folks about gallstone pancreatitis. When things are improving, we don't need to see biochemical normalization, but when the symptoms are improving, we go right to cholecystectomy with intraoperative cholangiogram and coordinate with you just in case there might be a need for an ERCP. There's been some studies done to show if you wait one day when the patient comes in with acute biliary pancreatitis, if the amylase lipase go up, then you do the ERCP because you got it, you have an impacted. But most of the time, it will go right down. And if it starts going down, they pass the stone and you can go to cholecystectomy. This is just from my standpoint, most stones can be cleared, some stones pass spontaneously, right? We have to use good judgment with that and local resource. You have to factor in what you have available to you. In summary, in neutropenic and thrombocytopenic patients with cholecystitis and choledocholithiasis, initial conservative management with antibiotics can be effective, particularly when spontaneous stone passage occurs. For gallstone pancreatitis, early ERCP is typically reserved for cases with persistent biliary obstruction or cholangitis, as many patients improve without intervention. The timing of cholecystectomy should be based on clinical improvement, rather than complete biochemical normalization with intraoperative cholangiogram, and ERCP coordinated as needed. Thank you for watching this video. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.