2024 Update Course - What's New on Biliary Stone Disease - Luke Neff, David Vitale, & Jeff Ponsky

Need because as Mac always says I do everything selfishly so that I get smarter. I said we need a review course because I feel like I can't keep up with like the stuff I actually need to know. There's a lot of publications, so I said to Witt, let's do a review course and Whitt said let's call it an update course. So that's where the name came from, but we made ground, we made rules that we have stuck to now for 11 years. Rule number 1. It had to be free to the world. That's what we've stuck to now. I said to Witt, how are we gonna ever pay for that? He said, we'll figure it out. And over the last 11 years, we've had mostly the same sponsors that have put this together for 11 years. And I'm gonna, I'll just say them now. Cincinnati Children's, Akron Children's, uh, Intermountain Health, Laurie Children's, Seattle Children's, O'Shea. Is it O'Shea or OShy? OSH, Cleveland Clinic, new this year, and Kansas City Mercy. Um, the original founders have been supporting this for 11 years to make this free to the world, so I'm so thankful for you guys to do that. Um, also, Storts and Medtronic are also helping us this year so that we can put this on for free. That was number 1, free to the world. Number 2, we had to do it in a way that democratized it no matter where you lived. So that's why we've been doing it remote. People don't have to fly here. We make it broadcasted so that no matter where you are, you can watch it and even after the event, you can watch it after. That was rule number 2. And rule number 3 was designed by my self-diagnosed ADD. I cannot sit and pay attention to long basic science talk, so you, you, what this was designed for is. No long drawn out talks about different molecules that I don't understand. This is practice changing what is new that you need to know to change in your practice now. That was the core essence of what this has been. Also, it's not so much lectures as fights, debates and arguments about how people should be practicing. This is the design of the event, so we ask everyone online, in person. If you disagree, make your voice heard. That's the purpose of this. We want to get voices together. Um, This year we're doing something to clarify because Cecilia, the, the 12th, OK, 12th annual update course. All right, this year we're doing something different because it was confusing people last time. So some of the things you're going to hear today. I would say you should be doing this. This is like if you're not doing this, you better think about it, change your practice. 2, this is something you may really wanna think about doing, but it's not wrong if you stick with the old way. Or 3, this is cutting edge only early adopters so we have labeled the talks green circle is an easy, no risk this is what you should be doing. Blue square is if you're, it's probably safe to do, but it's OK if you don't. Black Diamond, only the brave, only the brave can do this, OK? So some of you will see we've labeled you as green, blue, or, or, uh, diamond. All right. That's anything else. So I promise everyone, every year there will be technical issues. We've never in 12 years had an event that has been purely without technical difficulties. One year, the entire power grid went out in the city and we all got in 10 cars and drove to my, my house, and we did it in my living room. So we will always pivot, we'll always make it work. Um, and if, and if the worst case scenario, we will have everything recorded and you can watch it after. Um, what else do I need to say? If, if things start freezing up on your computer, we usually say restart your browser, but lately we have not had a problem with that. Anything else? I think that's pretty much it. Please, um, for the audience, like write your questions in the in the chat if we don't get to answer it live, um, all the doctors have here the chat, so they will try to answer it, uh, there so feel free to ask as many questions as you want. Yes, and we're gonna try to do better this year on getting all the virtual questions I did bad last year. Um, I, I also want to thank the people that actually did the work here. So Cecilia, M, Kiki, Ayla, uh, who else did I forget here? Uh, Carolyn, uh, we have, and Julie, Claudia, they put all this event together, uh, and, uh, James and your team, Red Bicycle, thank you. All right, let's kick it off. We're gonna get started. The first event is gonna be a recording that we always start with of highlights from last year. To update you on the big things that were presented last year. This was put together by M. Go and Carolyn Roberts. So let's, let's play the video. Shoot a gram, figure it out, because, um, quite often it's clean, right? And then you've, you've avoided a lot of needle pokes and a lot of, uh, imaging that is, uh, not without, I wouldn't say without risk, but just can be a real eye poke. So you avoid a lot of that and we reduce length of stay and the number of procedures that, that young kids are getting under general anesthesia. Um, so that, that's, those are the things that we're going to talk about. I'll turn it over to Doctor Vita for. Uh, ERCP, right, and we'll talk a little bit about ERCP and its role in, uh, cholodocholithiasis, cholelithiasis. I think, uh, Luke and I had a great time. I, I really appreciate the invitation to be here and, uh, we had a great time doing this at Cincinnati Children's for our, uh. Rounds and so we'll look forward to having an interesting talk and debate and discussion and Doctor Ponsky here offers a very unique perspective of being a surgeon that also does ERCP. It's good that he's sitting between us because he is the hybrid, right? Wait a minute, in full disclosure, this guy's father. Gary Vitale is one of the finest surgical endoscopists in the world who is a pioneer in surgical ERCP. Somehow he got into gastroenterology instead of surgery, but ERCP is in his blood through his daddy, and your dad and I go way back with this. So we'll talk more about who should do ERCP when we get to it, but, um, uh, it's, it's an important thing, and surgeons can do it. Go ahead. Excellent. Let's go to the next slide. All right. First clinical scenario, 15 year old female, 24 hour history of colicky right upper quadrant pain. Total bilirubin is 2.3. A little bit of an elevated lipase, not bad. Ultrasound is dilated. Oh, it shows a dilated common bile duct at 1.9 centimeters. There is a stone that is visualized. Uh, next slide. That's the, that's the scenario. Is there a slide up here? OK. What's our next step? What are we thinking? We're gonna give time for people that are remote to, uh, to answer, and, uh, we've got several options listed here. Um, let's just walk through them. Yeah, so, uh, you know, IV antibiotics, obviously, you know, we don't have any evidence that this patient has, we're just talking, we're giving people time. We're just gonna, we're in this room right now. IV antibiotics, MRCP surgery first call GI. We hear, we're hearing everyone saying surgery. Is there any wit is disagreeing what? Well, I don't disagree, but I think it depends in the setting in which you reside, in the hospital setting that you reside, and your own technical capabilities. Now we've had this discussion for 30 years, and, and I always come back to this one point that if you're, if you don't feel comfortable doing it, then you should, should you do X? If you have a GI colleague who you work closely with, should you do why, you know, that type of thing. So I think that's important because not everyone in the world has the same capabilities as everyone else. I love that point. You'll notice there's a bunch of asterisks on those two options, right? And that's specifically because, as I mentioned, all qualities is local. It depends on, you know, if you've got a unicorn, what are we people, what are people saying here? Incredible agreement. Everyone agrees. MRCP antibiotic first. Interesting. Call GI, yeah. That's why, OK, so it's a good topic. Exactly, yeah, so I think one thing we want to touch base on too is that we have definitely seen anecdotally and, and via literature stone disease is really increasing along with obesity and, and pediatric patients around the world. It's not just the United States issue. Um, and so we're seeing this with much more frequency now where we have children come in, even young children with, uh, biliary stone disease. So I think this is an important topic for us to cover. I think it's, yeah, I just make the other comment too, and, and we've, we've just recently published some, some work showing that a surgery-first pathway, or at least that mindset. And embracing that concept, um, really does reduce resource utilization, including MRCP and I don't know about your institutions, but that MRI scanner is running 24/7 because there's a lot of people who need scans. Some of them are lengthy. It's a, it's a precious resource. Uh, let's go to the, let's go to the, uh, the actual answer. I don't know. I don't remember what I put. I, I did these, this slide in particular. Yeah, surgery first. OK. So. Part of this is, um, I mean, we can quibble about this, but I did want to highlight, uh, Doctor Ignacio and the Webster folks. There's a couple of Webster members here in the audience that have contributed to this big Western Pediatric, uh, database, and they define this very specific and predictive score for, uh, choocholithiasis. It's, uh, I think a TBly greater than 1/8, uh, common duck stone visualized on ultrasound, and, uh, a dilated CBD. And it's actually, they ran it through, they held it, had a held holdout set, and they validated the model, and it's actually one of the most predictive models for choleidocholithiasis in this patient population, uh, that has ever come out. And so this is from the Journal of American College of Surgeons in 2023. And it's a great way to start a pathway, to have a pre-op pathway, you should incorporate, I'd say, maybe, a green recommendation for thinking about incorporating the duct score in your. Um, preoperative pathway for these, these children that are coming in through the, I'm in full agreement with that, and I think a lot of times before, as a gastroenterologist that does ERCP for children, before I even get a call, before anybody reaches out to me, the patient has had an ultrasound, they've had an MRCP, they've had all this workup, 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, you know, a combined, uh, uh, procedure with a laparoscopic cholecystectomy and IOC and potentially calling. Me into the room if an ERCP is needed, um, which our, our team at Cincinnati Children's does quite a bit, um, but, uh, you know, I think definitely utilizing score predictive scores like this is worthwhile on our patients. And let me just, this may be a black diamond recommendation, but let me just paint a vision for this. This score utilized in the ED surgery is called, we have the bandwidth and the OR availability. We go to the operating room, we intervene, you know, sometimes it's just some sludge or a small stone we flush it through. We have a clean. Graham, we're sending him home from the PACU. And then we always have to help Luke here. Graham chalangiogram, angiogram of the world, uh, in the podcast, we had to go back and change all those to, yeah, so I remember that. Yeah. Yeah, sorry. So the pendulum swings on this, or is it, is it more what JP you were going to say something, you know, this is flat, but 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. And if that kid gets pancreatitis and you could have gone straight to surgery, that was a mistake. So it depends what the surgeon can do. If the surgeon can't do a cholangiogram, well, that, that ends the game. Then you need to do an ERCP if someone can do it. If the surgeon can do a cholangiogram and even a choligotomy, if there's a big stone in there, then you go right to surgery. It's clear. So again, what Wit said depends on what you have in your institution. So, uh, and then this will probably just give you a softball for the rest of your thing, but. I always call myself out on this. I don't feel I'm great at stone removal intraoperatively because I've been so spoiled with ERCP. I don't know the tricks. I always call people like, what do we do here? Do we put a Fogerty? You get a basket. I don't, I've done very few in my career. So pediatric surgeons or general surgeons. I 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, uh, know how to put in a central line and you understand the principles of selling your technique, then you can do this. And, and I mean that's, that's the reality is like how do we democratize this because a lot of the stone disease, and, and I don't know if this is gonna be in here, but we recently published in JPS. And showed that we were able to achieve with a surgery-first mindset, and it was surgery first versus endoscopy, and this is multi-center. So this is not just in my shop, but with surgery first, uh, the stone clearance rate or the negative intraoperative cholangiogram, meaning no stones, uh, was 86%. And the, uh, 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, you know, ream the sphincter, that success rate was in the 90s. So it doesn't take much. And that's the, that's the dirty little secret is like, let's do something that, that I think is accessible to everybody. We're not talking about getting out koloidocoscopes or playing the claw game and burning these children with hours of fluoro as we try to fish these stones out. We're talking about doing stuff that's simple. Greg, Greg, go ahead. Real, real quick questions. Does your, does your algorithm change if the patient presents with signs of cholangitis? Oh, we're getting ahead of us. Yep, you're, you're a couple questions ahead. Good. That's good. Yeah, we should keep going. We should keep going. I was there to just push back on the choleidohotomy concept. I think, you know, clearing, um, ducts, great. Also, you have have to factor in age. A teenager, sure, you can do more aggressive things, but having had to fix bile ducts on smaller kids. It's it's not near as straightforward. This bile duct is 2 centimeters in diameter. It's as big as your wrist. But my point of that, yeah, but my point of that is, as you think about the spectrum of diseases that pediatric pediatric surgeons face, it's a little bit different profile than that of adults. And if this is a 5 year old, your algorithm might be a little bit. Let me be very clear, it's transcystic. We're talking about through the cystic duct. If you can't get in there, then I say you bail and you call a friend like I'm. I mentioned, uh, choleidokotomy should be mentioned in this situation, in my opinion, only to be condemned. You don't need to be opening up the common bile duct and fishing stones out when you have, you've got buddies. Wait a minute. I, I just have to disagree with you guys. There's some old surgeons here. The bile duct should belong to the surgeon. The bile duct should belong to the surgeon. This bile duct is almost 2 centimeters. That's a big bile duct. If you get in there and find a huge stone in there, 2 centimeter stone. Doing a cholelochotomy over that, making a small incision and popping it out is so easy that it is really worth doing. So I'm not saying you should do it in a 1 centimeter duct, but a 2 centimeter duct with a huge stone or multiple packed stones is easy to do. We should all know how to do that. So strive for that, David. Those are fighting words. I think, I think that's a black diamond, uh, situation there. So, you know, I mean. Multiple stones, big stones, um, you know, the risk, especially in a large duct like this was stone, the risk of pancreatitis with an ERCP goes down, as you know. Um, and so the cannulation rate is very high. Uh, you know, uh, uh, even in pediatric literature, when we're looking at stone cases alone, the risk of pancreatitis is less than 5% in the literature. So I think, you know, if you're talking about cholo dichotomy, uh, at least to me, uh, call a friend, you know, especially I'm gonna fist bump you on that one and, um, only because we got to democratize this, we gotta, you know, if you're trying to get traction with an idea or a concept and push it forward, you have to make it accessible to people. And if I was up here saying I agree with you. We all have the prerequisite skills, certainly in this room from an MIS standpoint to open up that duct, fish stuff out with a Fogerty or what have you, and then sew that duct up. Um, I don't think everybody's gonna have the appetite for that. So we gotta, we gotta get our wins where we can. So 85, 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? Because 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, it's sense they do, right? It's sense. They do. I think it depends on where you are and what you have, you know, um, at, at our institution, you know, if, if Greg or Nelson are in the OR, they'll call me. 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. Um, you know, stone cases most of the time are pretty quick. So I think, um, you know, that's what we do if you're in an institution where you don't have ready access to an ERCP doctor that's gonna come running to the OR. You put a clip on it, you close up maybe an endo loop because you know the ERCP is gonna happen soon. And uh and and they go in, you know, within the next day or two we have to, I, I got the, the, the signal that we have to move on. Uh this is just an example pathway came out of Vanderbilt. They did great work there uh we're gonna try to push this out to to people um so more to come on that next slide please. OK, we change it around a little bit. It's the Friday before Labor Day in the exact same scenario. And this, this only, and, and I, I made this slide, I did not consult with David, but this is only, uh, to stress the point that there are times when potentially, especially in centers that don't have pediatric endoscopists that are skilled in ERCP, uh, and you're beholden to your adult colleagues that may be in a completely different building across town or across the street, it can be more difficult. And so, um. I just turned the turn the temperature up a little bit on the scenario and would be curious to know if people have different thoughts based on that, but we can, we can move through this question pretty quickly. This is a poll. All right, so the poll's live, right? Has someone activated the poll? Polls live as soon as you guys think enough have responded, show it there. We have about 10 seconds for comments before we show the poll while we're waiting for people to catch up. Does, uh oh, what do you guys say? You've convinced some people here. Oh, we, we're changing the, yeah, hey, yeah, so I was gonna say the, the first couple of times you do this with the wire and dilator and the balloon and all that, you're gonna hate it. After you've done a few, the learning curve, it's really actually kind of fun to do, and I'd say the biggest keys to success is have all the stuff that you need to do this in one spot because nobody in the OR is gonna know what to get. Go shopping in IR. They'll probably be on vacation and not care. And you have to know how to break into the IHA storehouse of toys. You need like a really floppy tip and then get the right, uh, balloons. The 20 millimeter seems to be the best one. So yeah, and I, I don't know if we're gonna get to this because of the time, but towards I think it really depends on what you see on your IOC as well. If you've got a, a, a, a common bile duct that's chock full of. Three or 4 stones impacted there, you know, you're not gonna be able to be typically very successful with this type of technique, uh, you know, with surgery first if you see, you know, signs of, you know, some other things, uh, you may, you may want to call your GI colleagues. If you see one small stone and you flush and it doesn't come out using some of these techniques, uh, we have a question about that, yeah, exactly, yeah, exactly. So this, uh, only just to mention this briefly. On the answer slide here. Um, this is, uh, the Kocholithiasis Alliance for Research, Education and Surgery. It's a multi-centered group. It's a ton of fun. Uh, Doctor Jess Rowe has been the, the main herder of all the kittens to get a lot of these papers out, but one of them specifically is, is talking about after hours and weekend, and can we reduce length of stay with the surgery first mindset? And the answer is yes, and by a lot. Uh, next slide. Yeah, and I do want to point out that's a great study, great collaboration, um, all centers that do not have somebody that does pediatric ERCP, so that length of stay, I think, is probably influenced a little bit by waiting for an adult provider or transferring a patient and that kind of thing. You're right, but that represents the majority of, of the centers in the country. All right, clinical scenario number 2, We have an 8-year-old with sickle cell disease, elevated bilirubin, baseline's around 6, but this is, I don't know, 10 or 12, uh, lipase is normal. MRCP reveals stones in the common bile duct. What are our possible answers? Next slide. OK. So, again, we're a little bit of a nuance. We've got a smaller child, uh, something that seems to be almost elective in nature. I mean, it's up a little bit, but he's otherwise clinically fine. Does that change how we think about this? It worked. Thoughts from your perspective. Yeah, so I mean I think in our institution this patient would certainly go to ERCP. Um, now most of the time what we're trying to do, and I think we have an old slide deck here, so we didn't get a couple of slides in, but that's OK. Um, 11 of the things that we've published on as a group, uh, of pediatric gastroenterologists that do ERCP is that we can do same anesthesia ERCP with a cholecystectomy. So more than likely we would be attempting to have a combined OR time where we're doing an ERCP, especially in an eight year old like this with potentially a slightly smaller duct. We're going to do an ERCP and then the laparoscopic cholecystectomy will happen at the same time. Now, most of the time. Rendezvous if needed, right, yeah, so most of the time the lap coli is going to go first. There's going to be an intraoperative cholangiogram. They're gonna potentially try to flush, and I, I would caution, uh, when you're flushing, one of the things that can happen is if the stone is impacted, you can highlight the pancreatic duct. And I think as soon as you start seeing that pancreatic duct light up, that is a, a, a definitely, uh, um, signal to slow down. Your flush, be careful because you can cause pancreatitis in these patients just by flushing contrast into that pancreatic duct, uh, with a stone. And so when you're attempting that method, make sure you're, you're careful and watch out for that. Got you. It looks like we're about to split on elective Coli versus ERCP first. I think this, uh, this answer, elective coli is a little bit misleading because obviously you're gonna want to deal with the stones in the common bile duct, but nevertheless, uh, yeah, good discussion. I think, yeah, having. Having relationships, coordinating things, having all the, the tools at your disposal is really important, um, and you, you had a couple of questions that may not have gotten into this day so we'll have to, we'll we'll talk to this next slide. Um, this is just the, the same CARES group, and, uh, and, uh, again, the pre-vetting by Doctor Vitale, I just threw some stuff out there, but this is another study that shows, uh, and I've already referenced some of this data, 6% success rate. Um, and, uh, and I'll just put this out there, but the complications of the ERCP group, uh, it was a 10% complication rate, and that was cholangitis or bleeding of pancreatitis, or hemophilia and things like that. Uh, it's, it's a known thing. Uh, let's go on to the next question. This is just a, a toolkit. Um, this is, lives on the ABSA, the American Pediatric Surgical Association's, uh, Uh, website and it's just a, you know, a, a bunch of tips and tricks and videos and, and part ordering numbers and things like that so you can build your own kits. Uh, next, next slide. There's one This is the one I like. This is the one I wanted to talk about, and I really got a sense for this. I included it after a recent IPEC meeting where some of the South American sturgeons are talking about the rate of spontaneous stone passage. So this is a 16-year-old male. This is actually a patient of mine from about 4 months ago, uh, with right upper quadrant pain. He, uh, is currently being treated for ALL. He's neutropenic. LFTs are through the roof. Uh, the ultrasound is consistent for acute cholecystitis. And, uh, choloiddocholithiasis. OK. So now we have a little bit more of a different situation with the neutropenic, uh, thrombocytopenic patient. Um, what are we gonna do? So while we're waiting for you'll put the poll questions up, right? Yeah, let's throw the questions up. So the questions up. So while we're waiting, we have a question from the audience, so. So there's a question about what if it's an infant with stone disease in the common bile duct. Yeah, so I think from that standpoint, um, you know, we're really, uh, an ERCP is probably the best step, um, and it depends on what the stone disease is from, right, because we're gonna have a little bit more information about this. Does the patient look like they might have a colodocal cyst? Um, does the, you could do ERCP in an infant? Sure thing. So any, anyone, any, anyone. More than you know, we've done them in 3 kg babies, right, so we have scopes, um, and they're available in the United States, uh, for rental by anybody that just is, he's a unicorn. He's a unicorn people we can do you just smoked my dad because I thought he was Superman because he could do 3 year olds. Infant man. He's got. Uh, so it's, it's, it's, it's feasible. And I think, um, you know, a lot of times in those patients, there's one of two scenarios, right? It might be a patient who's had some surgical procedures, not been eating, is on TPN, and they've got some stasis and, and some sludge in the duct, um, that we can clear easily with an ERCP. The second scenario oftentimes is the patient may have some type of cholodocal cyst. They've got an obstruction and stones, maybe an anomalous junction. Um, and so we really wanted to define that well before you just go in and take a gallbladder. Well, I'm gonna push back on that a little bit because in this scenario for an infant, if you have the capability, you're probably going to have an MRCP to further delineate that and look at the ductal anatomy. So hopefully you have at least an indication of whether or not you're dealing with a congenital problem. If it's insipated bile, um, you can certainly, I mean, we're talking 5 French micropuncture through the gallbladder, a little wire, and you can flush that whole thing out. We've done that. We have a series of about 3 or 4 patients where we've done that, and I think that's gonna get published soon. And we leave the gallbladder, a little PDS in loop on the, on the gallbladder, and we're not, you know, we just kind of sneak in, do the thing, and get out. And, uh, so it is another option, another option. So there's just one other thing about a patient like this that's debilitated, a high risk for any incision anywhere. The ERCP, you can add to that back to the question. So we're off the, we're off the audience. We're going back to the snare. You can drain that duct without doing any incision in it. So if that patient's a high risk for bleeding or any surgical procedure, if you have to, you can do the ERCP and put in a small stent. To just decompress the duct and get rid of the sepsis while you get that patient in better shape for surgery. Yeah, absolutely true. And I think the most important thing in these type of cases is their cholangitis. Ascending cholangitis is an ERCP. I think without a doubt, you know, uh, we just had a patient come into our institution last week, norepinephrine in the PICU. Um, we're doing an ERCP. 5 hours after they showed up putting stents in, um, you know, so I think it really depends on the presentation of the patient. If there's a cholecystitis, we need to know is there a concurrent cholangitis, which a lot of times there is, especially if there's this young man, there was not. He was on the floor and doing OK, uh, but I will also, you know, take a, a green color recommendation for cholangitis is not the time just because you have a hammer, you know, that's not a nail, that's a screwdriver. You need to get a screwdriver. So I mean, ERCP would be the way to do it. Um, for we see some, there were, I think there was some responses there. Let's go back to the audience poll thing. Yeah, I mean, I think over half the people said, hey, let's with some antibiotics and let's trim these LFTs, and, uh, and that's what we did. And, 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. And I want to bring up one other scenario too for the audience, which is gallstone pancreatitis, which I think is a little bit different, um, you know, than our conventional show up with a, with a stone in the duct, um, and want to hear from maybe some people in the audience, you know, what is your management there because I think, you know, in my experience. It's a lot of surgeons. Some surgeon will go in and say, hey, we're going to do this, you know, the cholecystectomy within a few days. Some will say, hey, we're going to wait for a week. Um, you know, from an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this, uh, case right away. Um, so I just want to kind of hear from, from folks about gallstone pancreatitis. Nobody. Pargava Nelson, OK, stone pancreatitis. Definitely ERCP for us depend depending on how long the inflammation has been there. I wouldn't wait for a week to get the gallbladder out. If there are stones and the, you know, enzymes are coming down, symptoms are better, then I would take the gallbladder wrap. Yeah, we, 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, you wait one day when the patient comes in with acute uh uh biliary pancreatitis, if the amylase lipase go up. Then you do the ERCP because you got it, you have it impacted, but most of the time it'll go right down. And if it starts going down, they pass the stone and you can go to cholecystectomy. We've got just a few minutes. Let's, let's jump to the next question here. Um. Good discussion. OK. Uh, this is just from my standpoint, most stones can be cleared. Obviously, we've talked about a lot of the ERCP. Some stones pass spontaneously, right? We have to be, you know, use good judgment with that and local resources. This goes back to Doctor Holcomb's, uh, comment at the very beginning. You have to factor in what you have available to you. Uh, and for cer certain, you know, audience members in the, in other parts of the world that may not have ready access to fluoroscopy, for example, or that's difficult. Um, obviously, some of these techniques are, are more difficult to, to, uh, employ. Um, so all qualities local. Next, uh, next slide. OK, unsuccessful common duct exploration. You, you decide to flush and you get some glucagon. You do see contrast for those that have adopted this or started to dabble in this, um, you do see contrast in the duodenum on the intraoperative cholangiogram. Uh, let's see, that's our scenario. Um, let's see what, what do you do next? Let's get our answers up there. Hey Lucas We just learned how to mix the flush. does So the glucagon we just give, uh, one, yeah, so, uh, so the question is, what do we do for, um, our flushing for the intraoperative chalangiogram? What do we do with our glucagon? We're actually giving the glucagon systemically. Uh, some people are, are using a little bit of lidocaine in the actual thing that's injected into the biliary tree, uh, thinking that that may help rela relax things. I typically use a fifty-fifty mix of contrast and saline for all of my flushing maneuvers, um. So I hope that answers your question, but yeah, we give it systemically. We have the, the anesthesiologist do it. So what do you do in this situation? You got something you can't clear, contrast flowing in the duodenum. It looks like a, I don't know, 7 millimeter stone. Um, what do you do? I usually do a balloon sphincteroplasty and then try to flush it out still. OK, OK, you can do that with the Fogerty or you can actually get the balloon that you like using grab the balloon, grab a spyglass, OK. Who's calling? It'll, it'll depend on what, uh, you know, you have available to you. And also one thing, one point I want to make, that's a great point, Barga, but you can dilate the sphincter. One thing you want to be really careful about is do not dilate larger than the size of the bile duct. So if you've got a 5 millimeter bile duct and a stone that's not such so obstructive. You got to be careful. If you dilate that duct to about 10 millimeters, you're gonna cause pancreatitis. There's something that Dr. Ponsky taught me too about that actual dilation maneuver that you have to be really careful at. And I've, I've, ever since you said this, we've been employing this, but it's the idea that come up, get a little bit of a waste in the balloon, and just hold. Let that thing stretch slowly, and then you come up to profile in a very controlled fashion and leave it there for a while. We've been leaving it up for 5 minutes to avoid that rebound, uh, spasm of the sphincter. Um, OK. Somebody wanted to see the IOC, and I think that's great. And I'm gonna turn it over. I mean, not all IOCs are equal. We're trying to define that because sometimes you just see things taper down to a little nothing and that's just sludge. Sometimes you see a very well-defined meniscus. Sometimes you have these massive boulders and multiple of them, even in, in children. Um, and so I think that that is, uh, a really important thing is like, what do you have available to you? You've done a flush maneuver. You may want to take the next step. You may. You want to grab a balloon as somebody in the back set, um, and I think understanding what you're dealing with in terms of the, the burden of disease is really important. I think if I have a bunch of boulders, I'm gonna, I'm gonna bail stones, multiple large stones, you're gonna want to call your GI colleague. The other thing when you're flushing, you make sure you watch that stone, because if you flush that stone and it starts floating up into the bile duct and you make a very, very simple case with a stone sitting in the common bile duct. You can turn that into something very, very difficult if it flies up into the intra paddocks, um, which is a much more difficult ERCP. It can get impacted there. So you know, pay close attention. The bottom line is, I think, yeah, doing more intraoperative cholangiogram, getting comfortable with it, interpreting it, uh, getting the flow down, building the relationships with the people that, uh, that either need to be coming into the operating room or that we'll be seeing these patients after or maybe even before, uh, developing relationships and taking, taking just. A first little step and then the next step to really try to reduce length of stay and hopefully the number of procedures these kids have to go under. Is there another slide on the, and a lot of this is going to depend on local expertise, what you have available to you, who you work with in your hospital. All, all these things are very, very important. All right. Do you want to find a comment? All right, this, this was like a massively high yield session of about 30 different points. Um, again, we'll have all of this recorded, chopped up, and we'll submit all of these out so everyone can see it. I, as always, I practice like a historic dinosaur, so I'm learning the new ways now, so I love it. Thank you for, for putting this session together, the three of you. This was phenomenal. Thank you so much so much, everybody. Thank you. What a pleasure.