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

Stone disease is increasing along with obesity in pediatric patients around the world, not just in the United States.

There are two main approaches for patients with stones in the common bile duct who need gallbladder removal: ERCP first to remove ductal stones followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with intraoperative cholangiogram to identify and potentially remove stones during the same surgery.

A surgery-first pathway reduces resource utilization, including MRCP, according to recently published work.

A paper from the Journal of American College of Surgeons defined a very specific and predictive score for cholelithiasis.

ERCP adds potential morbidity to a procedure, and even with good technique, pancreatitis occurs 10% of the time.

If the surgeon cannot do a cholangiogram, then ERCP is needed if someone can do it.

If you know how to put in a central line and understand the principles of Seldinger technique, then you can do intraoperative stone removal.

In a paper published in JPS, stone clearance rate reflected by a negative intraoperative cholangiogram was 86% with a surgery-first mindset.

With minor additional techniques like advancing the catheter into the common bile duct or reaming the sphincter, the success rate was in the 90s.

At Cincinnati Children's, when surgeons cannot clear the duct, they call from the OR and an ERCP can be performed quickly in most cases.

At institutions without access to immediate ERCP, surgeons can place a clip or endo loop, close up, and perform ERCP within the next day or two.

According to Doctor 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 on the fly.

A common bile duct with 3 or 4 impacted stones is typically not suitable for surgery-first approach.

Doctor Vitale cautions that when flushing, if a stone is impacted, there is a risk of inadvertently injecting contrast into the pancreatic duct, which can increase the risk of pancreatitis.

When the pancreatic duct lights up during flushing, that is a signal to slow down because you can cause pancreatitis by flushing contrast into the pancreatic duct with a stone present.

A study demonstrated an 86% success rate for surgery-first, but the ERCP group had a 10% complication rate, including cholangitis, bleeding, pancreatitis, and hemophilia.