# Gallstone Disease — GCMD Library

This podcast is an interactive discussion about gallstone disease between Dr. Todd Ponsky and his father, Dr. Jeffrey Ponsky.

Dr. Jeffrey Ponsky is a professor of surgery at Cleveland Clinic Lerner College of Medicine, and is an expert in advanced therapeutic endoscopic treatment of biliary disease.

Intro track is adapted from "I dunno" by grapes, featuring J Lang, Morusque.
Artist URL: ccmixter.org/files/grapes/16626

Type: podcast · 47 min · posted 2020-12-30 Canonical: https://library.globalcastmd.com/watch/gallstone-disease-1379 ## Transcript Welcome to the latest episode of Stay Current in Pediatric Surgery. Today's podcast was created and edited by Nicholas Bruns, Alex Kassar, Ray Henke, and me, Alexander Gibbons. This discussion is extra special because it features not just one, but two Dr. Ponskis. If you think you can handle that, then join us and listen as they discuss Gallstone disease. And help us spread our message that knowledge should be free. Welcome to Stay Current in Pediatric Surgery. This is Todd Ponski. And today it's an actual very special day for me because this is a podcast I've been wanting to do for a couple of years now. We want to talk about gallbladder disease and biliary disease. And the person that we are interviewing today is my father, Dr. Jeffrey Ponski, who is professor of surgery at Cleveland Clinic Lerner College of Medicine and is really an expert in biliary disease, specifically endoscopy and ERCP and advanced therapeutic endoscopy for complex biliary disease. Dad, thanks for joining us here. Happy to be here with you. I know you're not a pediatric surgeon, but I know that from this regard, we pretty much manage biliary disease very similarly. And I know that we frequently call you to help us with some of our complicated biliary ductal diseases. You know, ironically, I've found very little difference in the management of biliary disease, particularly gallstones and cholecystitis between children and adults. And I handled both. So I think we can speak of them almost at the same time. Perfect. Well, let's dive right in. So let me take you through the more common thing that we see is a child comes in and they're complaining of right upper quadrant pain. How do you work up that patient? Well, the history, we all say, oh, well, it's just an old song to say you do the history first, but it's really important. Get the nature of the pain, how it recurs, what brings it on. You want to make sure you rule other things out. But then once you've done your history and you're suspicious that there may be biliary disease going on, the first thing we always do is an ultrasound of the right upper quadrant. And you think, well, that'll give you the results. And it often does. And if that shows you stones or paricholecystic fluid and thickening of the wall, you say, OK, I've got good evidence that there's biliary disease going on in the gallbladder. And you can move forward from there. When you don't see is the hard part. When you have a gallbladder, it essentially looks normal and without stones is when you have to be a little bit more circumspect. And very often you're sent a patient, often by a gastroenterologist, who says, I can't figure this out. The patient continues to have pain. I've done an endoscopy. I've done ultrasounds. I've done CT scans. And it doesn't show me anything. And what I add to that is I get a HIDA scan with a CCK ejection fraction. That is looking for a biliary dyskinesia. And the biliary dyskinesia is a real thing. You look for an abnormal ejection fraction, which we say is less than 35%. It should be higher than 35% when they give the CCK, the cholecystokinin. And if it's not, and every other test is negative, then you have presumptive evidence of biliary dyskinesia. And if everything else is negative, you may still take out the gallbladder. Okay. I think we'll get more into that later. Let's take this patient in particular. A patient comes to you, a 14-year-old overweight female comes to the emergency room with a 24-hour history of abdominal pain in the right upper quadrant. It gets worse after eating, and she's had similar episodes like this in the past. You get a right upper quadrant ultrasound, and it shows pericholecystic fluid, thickened gallbladder wall. Her liver function tests are normal other than maybe a little bit of an elevated ALKFOS and a white blood cell count of 13. What you're describing is a typical acute cholecystitis. Sometimes that same patient will present with intermittent attacks that sound like that. And when you get the ultrasound, all you'll see is stones without the pericholecystic fluid or the wall thickening. That's biliary colic where the stone falls back and the obstruction is relieved. In the case you're describing, the stone has not fallen back. They have cystic duct obstruction, which is the hallmark of cholecystitis. And that patient now has inflammation with pericholecystic fluid and thickening of the wall. That is an indication for cholecystectomy. And let's go back to that patient you mentioned that just had biliary colic. So no evidence of inflammation, but having an episode of colic. You would usually send that patient home and bring them back for an elective cholecystectomy? Yes, absolutely. Okay. Would you do any other preoperative imaging or that's enough for you? That is enough for me. Okay. So going back to our patient here in the emergency room who does not seem to have biliary colic, but actually does have evidence of cholecystitis. What's your plan? So let's say right now it's three o'clock on a Saturday afternoon. So when I was a resident more than a few years ago, we actually believed that it was good to cool the patient down by making them NPO, putting them on IV fluids in the hospital and waiting six weeks, not in the hospital, but when they cooled down, we sent them home for six weeks and then thought we would get a better dissection plane when we did the cholecystectomy. In the last decades, number of decades, it's been shown clearly that the sooner you can operate on them within the first week or so, the better off you are. So in this patient, I don't believe that if she doesn't have signs of peritonitis or if she's stable, I think you can wait until the next operating day, like Monday, and schedule her electively for laparoscopic cholecystectomy. So that would be at the discretion of the surgeon to either do it over the weekend or wait till Monday would be a reasonable thing to do? Absolutely correct. Okay. Do you put them on antibiotics? So that's been a debate for as long as I can remember, and many of my colleagues do. I don't believe there's any evidence that putting them on antibiotics helps. What about putting them on clear liquids? Is that okay while you're waiting for the OR? So if the patient is able to tolerate clear liquids and you're waiting over the weekend, there's nothing wrong with that. All right. So you go to the operating room. It's Monday morning. You get a spot in the morning. You take them to the operating room. Do you do this through four ports, three ports, or a single port? Well, I don't do single port lap coli. Many of my associates have tried it. I believe that laparoscopic cholecystectomy is a very challenging operation. You're always looking for abnormal anatomy, and your point of view is extremely important. Your ability to retract is extremely important. So in this case particularly, I wouldn't even consider a single port. Okay. In this case, I personally do four-port lap colis. Other people do three ports. Tell me where you put your four ports. Well, one starts at the umbilicus, unless there's been something there already. Okay. I do a direct cut down, the Hassan technique. Many of my colleagues now definitely use the Visiport, but I use a direct cut down at the umbilicus. And after that, I will put in the epigastric port. How do you decide where to put your epigastric port, not being too high or too low down? Well, the first epigastric port I put is just off the costal margin to the right of the midline. And I put it in under direct vision, looking at the liver. The first port I put in is the umbilical port, so I'm actually looking at the liver when I put in that port. It's usually to the right of the falciform, and I look at the angle at which it'll come in because I like it to be angled. I don't want it straight up and down. I want it enough to the left that I'm going to get a good shot angling it toward the gallbladder. Right. So do you put it a little inferior to the gallbladder so you're also aiming up and not straight up and down, or do you go at the exact level of the gallbladder? I go at the level of the left lobe of the liver. I don't go based on the gallbladder. I go on the edge of the liver. But this is all personal preference. The next port I put in is my right lower quadrant port, which is sort of in line with the anterior superior spine. And that is an important port because that's the one where I will next grab the fundus of the gallbladder and lift it up. That's important to put in first before I put in my last midclavicular port, because then that will show me where to put in the midclavicular port to have good access to the cystic ducts. Just to clarify where you put your ports, you put an umbilical port in, then you put your epigastric port in just to the right of the falciform ligament, about at the level of the gallbladder. That's exactly right. And then your next port is on the right side, lower, almost mid to right lower quadrant. That's right. You use that to grab the fundus of the gallbladder, lift it up, and then you put in your subcostal incision once you figure out the best triangulation. Yes. If you wait, if you put your midclavicular port in too early before you elevate the gallbladder, it will be too low. Interesting. You want it to be right in line with the gallbladder cystic duct once the gallbladder is elevated. If you put it in too early, you'll be too low at that port. So you've gone in, you're holding the fundus of the gallbladder with your right lower quadrant port, and you're grabbing the infundibulum with your upper right-sided port. Yes, that's correct. And you're dissecting with your epigastric port. Now... Can I stop you a second here? If the patient is what I call an A-frame, there are many patients who have a wide costal margin, and you can do the ports just as I described. An A-frame person is a skinny person whose rib cage looks like an A. Okay. You're forced to put your ports lower in those people because you can't get them in because the ribs are there. So you have to vary where your ports go based on where the gallbladder is. Your umbilicus and your epigastric port are fine, but then you have to elevate the gallbladder from below, but your midclavicular port will change based on the rib cage. So you're in there. Tell me some tricks. Let's say it's a very stuck gallbladder. This is when everyone starts sweating that this could go from an easy case to a complicated case. If you get in, you find a gallbladder that's a mess, and you can see it's a rock. First, you're going to have to take down the adhesions to the gallbladder, and that means you go very slowly, stay toward the gallbladder side, lift up the omentum and quadrate each little piece, and then push away, push down all these adhesions, until finally you work your way down to the infundibulum. If it's still, you don't see the anatomy well. These are the scary ones. When you see the anatomy, you can work on it and work on it, but it all seems like it's not clear. You can start higher up on the gallbladder and work downward, taking the peritoneum downward on both sides. The dome down. Yeah. I don't do a total dome down. People do that. I do it when I do open, difficult ones. But I start halfway up, because I use that dome for retraction. And I start halfway up, and I take the peritoneum and incise it a little bit, and then push down, and I work my way down that peritoneum on both sides until I'm at the cystic duct junction with the gallbladder. I like that. The modified dome down. The modified dome down. So I want to mention one trick that actually, when I had the pleasure of operating with you years ago, when you weren't yelling at me, you actually told me a great trick that I still use today, and that is that when you think you've seen your cystic duct gallbladder junction, you really haven't. You still can get more, which gives you a lot of length to keep you away from the common duct side, and that is to take your hook, and if you can see that thin peritoneum right at the corner, at the top of that cystic duct, you can usually get an extra centimeter than you thought. So that's absolutely correct. First of all, let me just say one other thing. The sucker is a great tool in dissecting the gallbladder. Using the sucker, pushing away with the sucker, using blunt dissection. I use hydro dissection in tough areas. I'll just put it where I think the cystic duct gallbladder junction is, between the cystic duct and where I think the cystic artery is, and just pump some water in. But once you think, and you just mentioned this, that you've got the cystic duct isolated, and you're between this, you're just taking your instrument, your Maryland, and you've dissected between the cystic duct and the cystic artery, that's exactly when I do that trick, and I didn't invent that trick. I will turn the hook toward the gallbladder, put it in that space, and lift up and cauterize. You'll get another half centimeter or so of cystic duct isolated, and that's where you can work. All right, so now you've done this, let's say it's an easy gallbladder. So the easy gallbladder is the one you should really be frightened of, because you get a little cure, you start telling people stories, you're laughing, you're joking. Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. I think biliary surgery can be terribly punishing if you make a mistake. All right, sometimes you go in and you lift up the gallbladder, and everything looks wonderful, there are no adhesions, and you can nicely almost see where the cystic duct is going to be right at the beginning. That's an easy case. And then you do your dissection in variable ways. In those cases, usually we'll start at Kellogg's triangle. You will take some of the peritoneum off the cystic duct by gentle pulling and tearing. Oftentimes I will take the hook cautery, and I will then incise the peritoneum along the lower side of the both lateral and medial sides of the gallbladder to get in that subperitoneal plane and push down away from there. And that accentuates the cystic duct gallbladder junction and lengthens the cystic duct to dissect behind the gallbladder at its lower portion. Not to rush to the cystic common duct junction. That's the last place you go. So I will often, in a routine gallbladder, take down the peritoneum along the side of the gallbladder laterally and a little bit on the peritoneum up toward the liver and then work downward toward the cystic duct, pushing away until you accentuate the cystic duct gallbladder junction. And then you can clean off the cystic duct and have a nice dissection. Do you do a cholangiogram? So an easy gallbladder, you do that dissection. Do I do a cholangiogram? This has been debated for as long as we've done biliary surgery and done cholangiography. The zealots tell you in every single case, particularly if you're in a teaching institution, do a cholangiogram. I have partners who do that. If it's not impossible to do it, you isolate the cystic duct. It's not punishingly short. You know, you can do it. Isolate it. If you have the means right there and put a catheter in, do a quick cholangiogram. That's great. Not only for stones, because you know this patient with a tiny cystic duct and a tiny common duct isn't going to have stones, normal function. But the reason you do it is to identify the anatomy and to make you better when you need to do transcystic exploration of the common duct. That being said, I don't do it 100% of the time. If I go in and this is a tiny cystic duct and it's a normal liver function, and the gallbladder is otherwise a reasonable gallbladder, it's a long cystic duct, I may milk it back, and then I'll clip it twice and proceed with the cholecystectomy. If there's any history of pancreatitis, even though it's gotten better, a history that the duct was slightly large on the ultrasound, if the patient ever had jaundice, then I will do a cholangiogram. Okay. So I personally don't do cholangiograms. I did them a ton in training, and now I don't. Just tell me how you do your cholangiograms. What do you use? I use the best catheter available, the one I invented, but here's how you can do it. There are many, many catheters available. A lot of people use a ureterocatheter, a spiral-tipped ureterocatheter. Ureterocatheters are fine. What I do is I first put, after I have the cystic duct isolated close to the gallbladder, and I have maybe a centimeter or two of space under it that I've isolated, I look at my triangle of Kelo, and I have it all dissected out. Then I will put a clip on the gallbladder side. Then I will make an incision in the cystic duct. And I used to have something called a micro-scissors to make a little incision. The nurses always couldn't find it or it was broken, so I just took the hook scissors or regular scissors, and you learn to make a slight nick in there or try to not cut the duct in half. And this is near the clip, a couple of millimeters proximal to the clip, closer to the common duct side of the cystic duct. So you've clipped it on the gallbladder side, then on the common duct side a few millimeters away from the clip, you make a little incision. I will take the catheter. I will have 10 cc's of full strength. Some people use half strength. It's actually better to see stones with. In the syringe, attach to the catheter, flush the catheter first. And I use the Olsen clamp because it steadies the thing. You put it into the opening, and some people will then put a clip over the catheter in the duct. All right? Or the Olsen clamp, you don't need a clip. And then you get a cholangiogram, and I like to do it under Cine fluoroscopy. I think it's great. If the contrast just goes down, if it only goes in the duodenum, some people say, oh, it's great. No. That's what I call the cholangiogram from hell. People, I used to give morphine, and then try to cause spasm of the sphincter, and then inject again and get the contrast to go up. Until Michelle Gagné, who was my partner for a time, showed me a great trick. Under fluoroscopy, with the Cine, you take the laparoscope through the umbilical port, you put it down where the papilla is on the duodenum, and you just press on that, and then you inject, and all the contrast will go up. It takes one second, and then you get a good cholangiogram. Okay. So you do your cholestectomy. Do you send them home from the recovery room? So we had an observation area for many years, and it depends on your local situation. I did these at outpatient facilities for years, and what I would do is give them in the operating room. And I learned this from the country doctors down in South Carolina many years ago. I was lecturing about how I couldn't send my patients home. They had too much discomfort. They said, oh, doc, don't worry about it. You give them all 30 milligrams of Toradol while they're still in the operating room. You have to get age-adjusted, of course. One dose of Toradol, it won't cause bleeding, in the operating room before they wake up, and you send them home. And they all went home within a couple hours afterward. I think we haven't quite caught up. I think a lot of pediatric surgeons still admit overnight or at least send them home later that day, so we send them to their room for a few hours. But I think we're catching up and starting to do the same. So let me take you through a couple of different case scenarios. Now you have a patient that comes in without not 24 hours of pain, but this patient has had a week of abdominal pain. What would you do different, or would you do the same thing? I would do the same thing. So is there a length of time where you would say, this is someone we should cool off and not do right now? It's been too long. Not necessarily. I really believe when they present, it's still the best time to do them. If the CT or the ultrasound is questionable. If you happen to get an ultrasound that shows a lot of paracolecystic fluid, and if you have, then you get a CT or something, and there's a collection, I might wait on that patient and settle them down. Okay. And that would wait at least four weeks or six weeks. Okay. But in general, someone with a week of pain, you would still do them. Okay. So let's say you did that cholecystectomy, and you get a call from the parents that about four or five days later, the patient is in just a lot of abdominal pain, more than you'd expect. How do you evaluate them? So here's the story. If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. My heart starts beating fast, but I have to prove to myself that it's okay. How do you do that? I have them come in, and this is the way I did it. A lot of people get HIDA scans. They love HIDA scans. I think HIDA scans are a good way to make money, but they don't offer me anything. I get a CT scan right away in the emergency room. If the CT scan shows pericholecystic fluid, a fluid collection, that's not my irrigation. I have them tap it. So an ultrasound would also work for that. Yeah. It's a little harder, but it's something. I just want to know if there's a fluid collection. If there's a fluid collection, right there, I tell them to tap it. If there's bile in the fluid collection, patient goes for an ERCP. Okay. Now, I've had a few patients where it's nothing. There's no fluid. In that patient, I get a HIDA scan, and it convinces me that everything's okay. Even if the liver function tests are normal, you still get a HIDA scan. If they have pain, I get a HIDA. First, I get the CT or an ultrasound, and then I get a HIDA scan. All right. So just to repeat what you would do, you would get some sort of imaging study, either an ultrasound or a CT. If there's fluid, you tap the fluid. If it's bile, you do an ERCP. Yes, because there's two things I want to rule out. One is a bile duct injury. I don't care if it's a cystic duct leak. Every single surgeon gets cystic duct leaks. Sometimes there's a clip abnormality, a difference between the size of the cystic duct or the clip, or there's necrosis. That doesn't matter. We can fix that. But you want to prove that there's no bile duct injury and don't want them to sit on a big bioloma. So tap it and go for the ERCP. And when you do an ERCP, you check to see if there's an injury, and then if there's a leak from the cystic duct, you do a sphincterotomy and a stent? Whether I do a sphincterotomy or not is unimportant. I sometimes do a small one to help the stent go in. In earlier days, we did sphincterotomies without stents because we didn't have stenting then, and it worked. But now we can put in a stent without sphincterotomy, but most of the time we do a tiny sphincterotomy and put in a stent, and the stent should be short. You want the shortest, biggest stent you can get in, so it's usually a 10 French, 5-centimeter long stent. It totally reduces the pressure of the sphincter, and the bile drainage will stop quickly. And then you bring them back six weeks later to remove it? Yeah, you can do it in six weeks or even three weeks. Okay. One other question before we get into the good stuff. So what about a patient that comes to your clinic that has chronic abdominal pain, and in their workup of chronic abdominal pain, they did a CCK HIDA scan, which showed biliary dyskinesia, so a low ejection fraction. Do you operate on those patients? If everything else in their GI workup is negative, yes. So now I want to get into really the questions that we have the most often for you and the most troublesome, and that is a patient that comes in with gallstones in their common bile duct. So let's take a patient that comes to you with abdominal pain. They have a elevated bilirubin of, let's say, four with mostly conjugated, and they have an elevated amylacin lipase. How do you manage that? Did the patient have pain when they came in? They came with pain. So this is gallstone pancreatitis. You know, Charcot's triad means cholangitis, and that means jaundice and right upper quadrant pain and shaking chills with fever. And that's Charcot's triad, and that is just cholangitis. But when they have abdominal pain and they have an elevated amylase and lipase, and oftentimes we just get the lipase because the amylase goes up and down, that's gallstone pancreatitis. Now, the rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. The stones that actually cause gallstone pancreatitis are the small little stones, and they cause the pancreatitis when they're passing by creating obstruction of both the bile and the pancreatic duct and tremendous pressure. So what we do with those patients is wait overnight and see which way the amylase and lipase go. If they start to go down, don't do anything. They go down, they go down, they go down to normal, wait a few days and operate on the patient, take out the gallbladder and do a cholangiogram. If they don't get better, if the patient does not get better, the jaundice is high, they're having worse signs of pancreatitis than you do to the sphincterotomy and clear the duct. The ERCP. Yes. Okay, so I want to make sure we highlight this because out of everything we're going to talk about today, I think this is the most important and also definitely the most moving target because this has changed during my time as a surgeon, and I want to make sure we emphasize what you just said. If a patient comes in with gallstone pancreatitis, my knee jerk used to always be to call you to come do our ERCPs. The big change now is not necessarily doing that, that when they present with gallstone pancreatitis, it often means that that stone is actually passing. Wait overnight, check their blood work, and if their blood work is normal, then you can schedule the cholecystectomy either on that hospital stay or soon thereafter. And I would recommend on that hospital stay because they just could come back again soon with another episode. Can I just say here, it's not fair. There are many zealots who say never get a preoperative ERCP if the patient's asymptomatic. Take them to the operating room, get an intraoperative cholangiogram, and prove they have common duct stones and see if you can take them out. In honesty, a lot about what we do depends upon local resources. Many people are uncomfortable with laparoscopic attacks on the common bile duct. Many people don't have the technical facilities, either the fluoroscopy or the cholangioscope, to do intraoperative work on the common duct. And so it is not uncommon in many places for the surgeon to say, look, I have evidence of a high bilirubin, I have evidence of a recent pancreatitis, please do a preoperative ERCP for me so I know that duct is going to be clear when I go to the operating room. So that's, although it's not ideal, it is real in many situations and I don't blame people for doing it that way. Okay, so let's take me, okay? We're going to talk about how I would handle this and here's my situation. I have done maneuvers, which we'll talk about, to try to remove the stone, but I would not say that I'm an expert in doing laparoscopic common bile duct explorations in the sense of opening up the common bile duct. So understanding that and understanding that I do have resources to send this out for ERCP, let's take that scenario. So here I am, I'm the surgeon, the patient comes in, they have an elevated bilirubin, the next day it's jumped up to six from three and the lipase went up again. So now it's not passing and now I'm stuck. Do I send to you for ERCP or do I take that patient to the operating room? I would do the ERCP on that patient. There's an old rule that patients who have persistently elevated bilirubins should probably have a preoperative ERCP and I believe in that. So now I'm confused because I thought you had mentioned that these patients we should go in, do the colosteck, we try our best to get the stone out and if we can't then send for ERCP. This is where I'm stuck. But in your situation, getting an ERCP is not always easy for you and I think that in, again, local facility, you have to send the patient out to get an ERCP. You might argue to do the ERCP, clear the duct and let you do the cholecystectomy. So you could do it either way. You could do it either way. Many people, if you talk to George Bursey, if you talk to Joe Peatland, they would tell you, take that patient to the operating room, as you just said, do a cholangiogram at surgery and clear the duct in surgery. Then if you're unsuccessful, send him for post-op ERCP. Joe Peatland won't fail. Joe Peatland will either do an intraoperative transcystic clearance of the duct or he will do a trans laparoscopic choledogotomy and clear the duct. Okay. So let's say I actually happen to have access to ERCP at the different hospitals I work at. But let's say I decide that I want to go to the operating room, do my best shot at clearing the stone intraoperatively. And if not, then my plan would be to send for ERCP. So let's say I go to the operating room. I go in, I put my ports in, I do my dissection, I've got my cystic duct dissected out. Tell me the maneuvers I should be doing to try to clear this common duct. All right. Make an opening in the cystic duct. Okay. And then milk it back with a Maryland, just opening and closing the Maryland over the cystic duct. Okay. And if you see stones coming back, that's a good sign that may be something in the common duct. Although they often stop little ones at the valves of Heister. But you do a cholangiogram. And what does the cholangiogram show? The cholangiogram shows a disc-shaped opacity right at the junction of the papilla there. So that's a meniscus sign. Meniscus. And you suspect something. Very often, what I will do with that is give a milligram of glucagon in an adult-sized child. A milligram of glucagon. A milligram of glucagon. I'm saying that again because when I'm in the operating room, I never remember. An amp. Okay, one amp of glucagon. It won't hurt them. Yeah. You can give a milligram of glucagon. Tell a story about a good vacation you went on for about a minute or two. A minute or two. To let it work. Okay. And then flush with some saline. Okay. And then do another cholangiogram. Okay, and it's still there? It's still there. Do you do it again? No, that was enough. Okay. The next thing I would do is take a wire. And I do this in my operating room. Many of the cholangiogram catheters come with wires. You take the wire, a soft-tip wire, pass it through the cystic duct and under fluoroscopy, see if you can pass it into the duodenum. Okay. Very often, what you have may be a pseudomeniscus sign or even a small stone. And you may knock it through with the wire. Okay. And it may work. Okay. So if it doesn't, let's assume it doesn't. I want to make sure something you said. Back when I was a resident, I remember seeing someone injure the common bile duct with the wire with that technique. So you said a soft-tip wire. Soft-tip wire and never push against resistance and watch under fluoroscopy. Okay. And the other thing is, many people say, oh, the next thing you're going to do is get the choledocoscope. I work at a great institution and oftentimes I can't get the choledocoscope. It's broken. The new one isn't in yet. Da-da-da-da. So what do you do? Good people all over the country will take a dormia basket under fluoroscope. You saw that meniscus sign. They will put the closed dormia basket down and see if they can pass it into the duodenum. Then they will open it up a little bit and pull it back slowly without closing it and jiggle it in the distal duct. Jiggle, jiggle, jiggle. You may find yourself catching the stone and just pull it out of the cystic duct. Sometimes you'll get the stone that way. Can we use a Fogarty the same way or no? You can use a Fogarty the same way, but in the Fogarty, what you have to do is you put in the duodenum, you blow up the balloon, pull it back till you feel the popola, let it down for a millimeter, then pull it back and blow it up again and pull it back. What size Fogarty balloon? Five. Okay. I just say five. I just always wondered what size is too big. And if the nurse tells you we don't have biliary Fogarty, she'll say good, go to the vascular room and get number five Fogarty. Okay. Just longer. Number five. Okay. So just to repeat, we've tried the amp of glucagon, we've tried the basket, we've tried a Fogarty, and still the stone is there. If you had the choledocoscope, you can put it through. Sometimes you may have to dilate with a balloon, the cystic duct a little bit, but the new choledocoscopes are very small, less than three millimeters. You can pass it down the cystic duct under direct vision. You have to let saline go through it, so fill up the duct. And if you see it, and it's a big CCD camera, you can see it. You can either grab it with a dormia or put a balloon distal to it and pull it up. You almost trap the stone between the balloon and the scope and pull it out through the cystic duct. Okay. All right. That's the tricks. Okay. I take out the gallbladder. Do you recommend putting endo loops or a stapler on the cystic duct stump since you're going to be doing the ERCP afterwards? So that's usually the real, the problem isn't the ERCP. The problem is if you're waiting a long time and they have a obstructed duct, they can blow your tie off. Okay. So anytime you transcystically explore it, it's good to put endo loops on it. Okay. Even if you clear it. Some people early on would put a pediatric feeding tube in the cystic duct and bring it out laterally and drain this common duct, temporizing it. And you can do that, but you put endo loops around it, but it's not always necessary. Okay. So just to repeat, because this is the part I really wanted to talk about. Patient comes in, they have gallstone pancreatitis, we admit overnight. That's undeniable in that situation, unless the patient is there. Unless they're very septic. Still, you're going to... Hydrate them and get antibiotics. Yeah. Okay. So you admit the patient overnight, you watch to see how they're trending. If they improve, you take out their gallbladder. If they don't, then the decision is based on your facility. This is sort of dealer's choice. You can send them out for ERCP or try your best at an intraoperative exploration, transcystic. And if that doesn't work, you can send them out for post-operative ERCP. However, some people will do a true laparoscopic common bowel duct exploration. It's a great operation. There are a few caveats. Number one, you want a dilated duct to do it in. You don't do this in a normal size duct with small stone. What does a dilated duct mean? I want a duct that's over a centimeter, a centimeter and a half. I like them when they're two centimeters. It makes it easier. But if it's a small duct, don't mess with it. Send it for ERCP. You're going to, you take a chance of stricturing it or injuring it. But a larger duct, fine. So the tricks in doing a lap common duct exploration are first stay cool because at any moment you can convert to open. But let's assume that you are going to do it. Don't divide the cystic duct. You use the gallbladder to retract laterally. You keep wiping that cystic duct down toward the common duct with a blunt disector. And, or the suction. And you'll see that there's loose peritoneum and loose fat over the anterior surface of the common duct. You just keep wiping and wiping and you'll see the anterior surface of the common duct where the cystic duct joins it. At that point, if you're not sure it's a common duct, you're uncertain, I take one of our big aspirating needles and poke it right in there and see if you get a little bile. Usually even through the needle hole, you'll see bile. Then I will take the hook cautery or a tiny scissors. And just at the point where the cystic duct meets the common duct, I will go a millimeter or two above that and bovie a little hole in the common duct. Okay. And then you can take your scissors and spread that little incision. You can make an incision for a half centimeter. I don't make the incision too big right away. Okay. And I will then go downward with that incision toward the duodenum. And then what? So you've opened it up. A lot of times when you open it up, it pops out. Okay. But don't, then I would take a red rubber catheter, a number 10. I put it on a syringe. You can put it through your five millimeter port. You put it down the common duct. Flush, flush, flush, flush. Put it up the common duct. Flush, flush, flush. That may do something. If it doesn't, then you use your Fogarty up and down just like you did to the cystic duct. But this time you can go up and down. Then you want to see if you can get a choledocoscope or a nephroscope. Go up and down and see if it's clear. I always wondered about this. You can look with a choledocoscope, but you've lost your opportunity to do any more cholangiograms now. Not entirely. So some people will put a T-tube in and, you know, and do it through the T-tube. It doesn't make it easy. You're exactly right. You're exactly right. All right. So you have somewhat confidence that you've cleared it. You close it with interrupted PDS? What you do is I put a T-tube in. Other people don't. Okay. So what I would do, if they had a previous sphincterotomy, you don't need a T-tube because it's going to flow distally. What I do is, this is an old surgical trick. You take a T-tube, maybe a 14 or a 12, and you cut it about, I would say, about an inch on each side of the T. You bevel the edges and you cut half that back wall off. That makes it come out easier when you're done and also go in easier. I always put the bottom end in first and then I bend the top end and pop it in. Okay. How do you tie it? Well, when I first started doing this, I wasn't very good tying. So I always told people, I use 4-O-G-U-C-Vicro. I would take it, put it through both sides. First stitch goes below so that the T-tube can rest on it. And I would twist it like a twisty and put a clip on it to tie it because I wasn't very good at tying. Okay. It worked. Okay. But now you know how to tie. So you put your stitch in, you put four knots in the Vicro. And then I push the T-tube down toward the duodenum, resting against that stitch, and put all the rest of my stitches in, interrupted from the top. Some people use a running. Okay. And what do you do with the tail of the T-tube? You put the whole T-tube in the abdomen while you're doing this. You don't want it sticking out. At the very end of the case, the last thing you do is take out the gallbladder. Then you're going to put in a drain, a JP in the frame of Winslow. And then you put your T-tube, you bring it out through one of your ports. Okay. With a tiny little bit of laxity in it. Laxity. Yeah. Okay, great. And how long do you leave that T-tube in? At 10 days, we get a cholangiogram. Okay. And then if that's okay, I used to pull them out at 10 days, leave it in a couple of weeks and pull it out. Got it. Okay. So I have a case for you. So what about a patient that comes in with gallstone pancreatitis? Their gallstone passes, but now they have bad pancreatitis. Okay. How long should you wait? Do you wait for once their symptoms are resolved? Is it safe to go in then? Is it too inflamed? Do you bring them back in a while? I would like to get a CT on that patient. Okay. Because if they have a big phlegma in the head of the pancreas, it's going to make your dissection harder. If you can wait six weeks, it's probably better. But we used to say after the gallstone pancreatitis settled down, before they leave the hospital, you should take out the gallbladder. Okay. Occasionally, you're going to see a patient where you do your cholangiogram and there are tons of stones going up the common duct. First of all, that's hard to do laparoscopically unless you do a choledocotomy. But more important, if you have stones going back up in both branches and the duct is very dilated, and maybe the patient has a propensity to be a stone maker, like a sickler, for example, you might consider in that big dilated duct doing a choledocoduodenostomy. And that could be done laparoscopically or open. We used to do choledocodaginostomies, but a choledocoduodenostomy is an excellent operation. Make it big enough. I would make it even two centimeters, the anastomosis. And that will be a good way to provide what we call a drainage procedure so future stones will fall through. Okay. Just some random questions here. Patient comes in, they have a really bad history of abdominal pain. You get your ultrasound or CAT scan, which shows what looks like to be a large phlegma on there in the right upper quadrant. How do you manage that patient? Well, if they're acutely ill with high fevers and stuff, you may have to say, you know what? This patient is not going to be an easy operation right now. Maybe I could do a percutaneous cholecystostomy, temporize the situation and wait six weeks. Okay. Would you do the same thing for someone who happened to have comorbidities? Is it safe to put in? It depends. If they have a clotting disorder, that's something you don't want to put something through the liver. But if the patient has normal clotting studies and they're otherwise not going to be a great operative risk, percutaneous cholecystostomy may be a good temporizing situation. Sometimes you get into an operation. Let's say you operate on that patient and you can't recognize anything. You want to call your mommy for help. This is scary. People talk about a fenestrated cholecystectomy or they talk about a partial cholecystectomy. I went in on one lady and she had varices all over her gallbladder. I was scared to death to touch it, but she had bad gallstones. I opened her gallbladder at the fundus, cleaned it out, took out half the gallbladder, stapled across it and said goodbye for today. So you left the back wall. I left the whole distal gallbladder. Okay. But in the other patient, for example, you get in and everything's attached to it. You're trying to peel it down. It's tearing. You can't find anything. Some people will just take off the anterior wall or it falls off. I will bovie the back wall to kill the mucosa. Sometimes it's already... You sometimes would like to put a little clip on the cystic duct, but if you can't even see where the origin is, just put a bunch of drains in there and settle for a controlled leak. When people mistakenly divide or injure the common bile duct, what is usually the mistake that's made? Why does it happen? It happens because they're doing this easy case or they're not... They didn't do a cholangiogram, but they're doing this easy case and they're flying across it. Sometimes the common duct will come up right to the gallbladder and it takes a bend, like a knee. So it looks like a cystic duct. It looks just like... I have videos of it. It looks just like the cystic duct goes right up to the gallbladder and then if you keep dissecting with your suction, you'll find it looks like a knee and then it takes off to the patient's left again. It goes off to the right a little bit from you. Then it goes up toward the liver and if you keep dissecting, you'll find a two or three millimeter cystic duct that comes off that knee. If you can get on either side of it, could it still be the common bile duct? Is it possible? Yes, I've put endo loops around the common duct and lifted it up for retraction only to find I was around the common duct. So just because you can get around it doesn't mean it isn't the common duct. Okay. You must dissect the cystic duct gallbladder junction perfectly. Okay. So I'm doing a tough gallbladder. I think I see the cystic duct. I go ahead and I cut into it and I realize that in fact, I think I've just cut into the common bile duct. So the first thing you ought to do is stop. Stop. This could happen to anyone. Understand this. If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. Have them look at it with you. Certainly some people would convert. Okay. If you don't have the ability to do a hepatic oj genostomy yourself or if you're shook, you should not do it. There's no rush. Put a bunch of drains in there. Call a colleague who's a good hepatobiliary surgeon and go ahead and fix it and let them fix it. Ship it out. You don't want, because what happens in most of these cases is the primary injury is compounded by the attempted repair. Is that right? Yes. And a primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. The other thing is, sometimes you may do a cystic, a trans, you may find that you, during your cholangiogram or whatever, you actually cause a lateral injury in the common duct. It's a little hole. That you can stitch closed. Not only not stitch it, I would put a little tiny T-tube in it and just bring it out. Then you have a controlled leak, you let it sit for a while and it'll come, and it'll heal. So a little hole, you wouldn't just put a stitch in? No, a stitch is a leak. Interesting. I would put, if it's a little hole, I'd put a T-tube in it. You could try to sew it up and put a drain next to it. Then you have to make the hole bigger in order to do that. I have. I've taken the tip of a maryland, stretch it just a little bit and put a little T-tube in it. Okay. So if I've totally divided the common bile duct, how do I do damage control in that situation? Often you won't even know that you did it except you don't recognize where you are. Okay. If even if you see the proximal common bile duct, the distal end, you could leave it alone. I would leave everything alone. I would put a bunch of drains up where you think you, if you try to put a tie on it and a tube in it, you'll compromise the amount of bile duct left for the guy who's going to do the hepatic. So leave it alone. Leave it alone. Drain it well. Okay. And transfer the patient. Okay. Great. Well, Dad, this was not only very educational for me. I know that this is stuff that I've struggled with, these difficult cases. And I know that you have been a great resource for me. But more than that, it's actually been an honor that I've been waiting for to interview you and to have you as part of our podcast. So thanks for joining us today. It's my pleasure. A lot of fun. Thank you. Thank you. Thank you. This is Alexander Gibbons from Akron Children's Hospital, the contributing editor for this episode of Stay Current Pediatric Surgery. We hope that you enjoyed this discussion between the two Dr. Ponskis, father and son, as I went through some of the intricacies of gallstone disease. If you're listening on the new Stay Current app, we invite you to join us on the community section to discuss what you liked and what you thought we could do better for next time. We would also love to hear your ideas for different topics that you'd like to hear in the future. Next month, we'll be discussing pediatric critical care. Thanks again for listening, and until then, remember, knowledge should be free. you, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, I like a part-in, the thing, the thing, the thing, the thing, the thing, the thing, the thing, the thing, a all, a one,,, Thank you. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai